Provides customer service in a face-to-face setting for health plan members, providers and group representatives on health plan products, benefits, and provider networks in a face-to-face setting, deescalating emotionally charged customers as necessary. Explains the benefits available to members and providers and determines the company’s liabilities and obligations in varied medical circumstances. Resolves complex inquiries from internal and external customers. Processes regulatory and non-regulatory non-phone work. Ensures compliance with department and regulatory requirements.

PRIMARY RESPONSIBILITIES

• Educates and informs members of available benefits under the health plan and coordinates the exchange of information among members, providers, and internal departments.
• Instructs members how to receive maximum benefit reimbursement, including utilizing their primary care physician and network providers; and processes regulatory and non-regulatory non-phone work, such as, CMS Health Insurance Casework System and CMS Complaint Tracking Module, e-Form requests, post authorization items.
• Determines various policy provisions, guidelines, providers, and provider requirements and procedures; medical review procedures; and the procedures of company departments that apply to the need of the member.
• Accesses and researches various information databases to provide answers and make appropriate decisions about the caller’s situation.
• Documents each phone call in accordance with department’s standards, monitors the types of inquires received, and reports trends and concerns to management.
• Stays abreast of related regulatory, compliance, and departmental updates to meet departmental metric requirements.
• Investigates specific circumstances surrounding a participant’s concern and resolves or makes recommendations to a supervisor.
• Assists in the department’s efforts to continuously improve service by recommending changes to current practices, identifying needs for additional training or references, and assisting in implementation of approved changes.
• Performs other duties as assigned.

EDUCATION

• High school diploma or equivalent

EXPERIENCE

• Two years’ experience

PHYSICAL REQUIREMENTS

• Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs.
• Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements.
• Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors.
• Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc.
• Frequent keyboard use/data entry.
• Occasional bending, stooping, kneeling, squatting, twisting and gripping.
• Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs.
• Rare climbing.