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Customer Service Representative

4 months ago

Stockton, United States P3 Health Partners Full time

**SUMMARY OF DUTIES**:
Communicates with a diverse customer (member/provider/health plans) base, regarding individual questions and concerns specific to plan benefits, coverage determinations, event information, claims status and complaints, conducts inquiries and research related to questions and concerns. Coordinates with others within and outside the organization to facilitate timely resolution of member, provider and health plan issues.

**MAJOR DUTIES**:

- Takes inbound calls and responds appropriately to all customer questions and/or concerns.
- Provides information as requested by caller related to eligibility, claims, providers, vendors, or other processes, including grievances and complaints.
- Provides information as requested related to coverage determinations and appeals processes.
- Maintains applicable records and files regarding customer communications and service coordination.
- Reviews all documents received for completeness, verifies eligibility of both the member and provider/vendor, and if applicable contract status.
- Verifies claims status and coordinates information, as applicable, with provider and claims staff.
- Forwards calls as required to appropriate supervisor or clinical staff for further response or follow up.
- Ensures confidentiality of all hard copy, electronic, and verbal communication, and adheres to organization’s policies related to privacy and disclosure.
- Promotes a positive image of the organization and the department in all aspects of communication and contact.
- Performs other related duties as required

**PERFORMANCE STANDARDS**
- Receives inbound calls from members, providers and others and facilitates response and closure.
- Makes outbound calls to coordinate information, service and communications.
- Takes appropriate and timely action regarding problem resolution.
- Uses translation and language services appropriately and timely.
- Refers member or provider calls that require clinical assistance to appropriate clinical staff.
- Maintains applicable files and documentation in an organized manner.

**KNOWLEDGE/SKILLS**:

- High School Diploma or equivalent
- Knowledge of medical terminology a plus.
- Ability to communicate effectively with co-workers, physicians, provider offices, and members a must.
- Ability to work under pressure a must.
- Ability to work independently a must.
- Problem solving skills and ability to set priorities essential
- Word processing/computer data entry experience with ability to type at least 45 wpm with good accuracy, and accurate and speedy ten key skills.

**EXPERIENCE**:

- Previous experience in customer services or related function in health care organization preferred.
- Experience in a managed care environment preferred.

**Education**: Required
- High School or better

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

The contractor will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the contractor’s legal duty to furnish information. 41 CFR 60-1.35(c)