Customer Service Representative Senior

3 weeks ago

Fremont, California, United States Info Way Solutions Full time
Job Summary

The Customer Service Representative Senior is the primary point of contact for CalOptima Health members and providers, providing assistance with inquiries related to Medi-Cal programs for Orange County. The incumbent resolves member complaints and inquiries fairly and effectively, providing information on eligibility, enrollment, benefits, and services to CalOptima Health eligible members and providers.

Key Responsibilities

• Participate in a mission-driven culture of high-quality performance, focusing on customer service, consistency, dignity, and accountability.
• Assist the team in carrying out department responsibilities and collaborate with others to support short- and long-term goals/priorities for the department.
• Address member inquiries, questions, and concerns in all areas, including enrollment, claims, benefit interpretation, and referrals/authorizations for medical care.
• Verify member eligibility, claim, and authorization status for providers.
• Responsible for thorough follow-up and completion of all member and provider inquiries or requests.
• Maintain departmental productivity and quality standards.
• Provide follow-up assistance as needed.
• Route escalated calls to the appropriate Member Liaison Specialist, Supervisor, or Call Center Manager.
• Adhere to departmental policies and procedures.
• Process all member transportation requests within one business day of receipt and coordinate all aspects of the process with the clinic, provider, and member as appropriate or necessary.
• Assist members with CalOptima's Member Web Portal registration and technical support.
• Interact face-to-face with members by assisting with front desk coverage.
• Serve as a backup for Customer Service Leads, as needed.
• Handle and resolve escalated issues.
• Compete other projects and duties as assigned.

Requirements

• High School diploma or equivalent required.
• 2 years of experience in a customer/member service or call center capacity required.
• Bilingual in English and one of CalOptima Health's defined threshold languages (Arabic, Farsi, Chinese, Korean, Spanish, Vietnamese) required.
• Preferred Qualifications: 2 years of Health Maintenance Organization (HMO), Medi-Cal/Medicaid, and health services experience preferred.

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