Our Customer Experience Teams receive incoming telephone calls from our members. Our Call Centers are open 7 days a week. If hired, you will be required to attend and complete a paid, mandatory training. Training will be held in a remote environment. Remote training requires secure, reliable internet connectivity. Any hybrid work or training requires both remote and on-premises attendance facilitated at various Blue Shield of California work locations throughout California, dependent on business requirements. Blue Shield of California is a hybrid work environment, dependent on business requirements. All training attendance is required, training 8 hours each day. attend each day for 8 hours.

Job Summary

As a Customer Service Representative (CSR), you are in charge of upholding our mission of providing a service worthy of our family and friends. You are empowered to provide members with peace of mind that their current issue is resolved and that none are on the horizon. 

Successful CSRs deliver an effortless customer experience by: 

• Taking the lead – our CSRs take ownership of members' issues, relieving members' stress while guiding them to a quick and easy resolution. 
• Identifying future problems – not only do our CSRs solve the current member concern but they actively identify and solve any lurking complications the member may encounter after their first interaction. 
• Sharing insights with peers and management – our positive team culture relies on open communication to continuously improve how our work gets done. 
• Having fun! – our work is important, but we don't take ourselves too seriously. We love helping others and have a fun community dedicated to doing so! 

You must also be:

• Available to work a scheduled 8-hour shift, which includes 2 scheduled breaks and a lunch period, also available to work and weekends and occasional holidays as part of your regularly scheduled shift.
• Patient with Members who call into our Centers with a question or a problem.
• A good listener and not only answer the questions they ask you but identify and answer questions the member may not be aware they needed.
• Comfortable using a computer with 2 display monitors to allow you to navigate to multiple screens for information.
• Comfortable using Excel spreadsheets to calculate Member premiums for health insurance.
• To multi-task using a computer; talking to the member and entering Member information into their online record.

Your Work 

Responsibilities include: 

• Resolve incoming calls concerning member's eligibility, benefits, provider information, monthly premium billing, clinical and pharmacy needs.
• Compose routine and non-routine correspondence to answer benefits/provider inquiries in writing.
• Coordinate membership changes such as member's primary care physician.
• Perform routine to mid-level inventory reduction (i.e., member inquiries, may initiate claim adjustments, respond to emails, etc.)
• Review and analyze member claims for accuracy as well as member education on how benefits are applied.
• Participate in quality and efficiency workgroups to continuously improve quality member/customer satisfaction as requested.
• Proactively analyze available programs, determine program eligibility, and connect the members to appropriate BSC vendors, Health Advocates, Social Workers, Pharmacy Techs, and Pharmacists. Verify the member is included in or targeted for any outreach or care gap programs and connect members to programs or services when appropriate. Engage members with their wellness plan options.
• Comprehensive resolution of pharmacy calls concerning benefits coverage, co-pays, formulary coverage, vacation overrides, and utilization management requirements 
• Provide prescription-related benefit coverage (e.g., explanation of coverage or benefit summary related): Provide prescription co-pays. Provide prescription formulary coverage information and utilization management requirements using web-posted printed formulary. Provide a brief description of coverage denial reasons and alternatives listed in the printed formulary. Perform prescription claim overrides. 
• Provide deductible and max out of pocket information. 
• Provide status of a prior authorization requests 
• Assist members with when and how to appeal a coverage decision.
• Continued learning and comprehension of procedural changes requiring reading and understanding changes.
• Other duties as assigned.