POSTED: May 2, 2024
POSITION: Customer Service Representative
DEPARTMENT: Operations/Customer Service
POSITION SUMMARY:
Serves as customer service liaison for providers and members while representing the Upper Peninsula Health Plan (UPHP).
ESSENTIAL DUTIES AND RESPONSIBILITIES:
1. Follows all established UPHP policies and procedures, objectives, safety standards, and sensitivity to confidential information.
2. Meets established production and call performance metrics, as determined, and ensures a positive customer service experience for members and providers. Documents all member and provider correspondence in Plexis Claims Management (PCM) database.
3. Assists members of all UPHP product lines with questions regarding benefits, policies and procedures, eligibility, formulary and medication denials, provider information, and getting care.
4. Assists members of all UPHP product lines in filing and/or resolving complaints, grievances, and appeals.
5. Maintains provider relations with medical providers; assists with member issues, answers eligibility questions and questions regarding benefits and the Medicaid Fee Schedule & Medicaid Services Administration (MSA) manual; reviews formulary and medication issues and routes to pharmacy as needed; provides information related to grievances/appeals.
6. Assists pharmacy providers by answering eligibility questions, providing instructions on pharmacy processing, giving information on formulary benefits, researching medication denials, providing medication appeal instructions, and routing any issues to the pharmacy department as necessary.
7. Keeps abreast of all UPHP Medicaid, MIChild, Healthy Michigan, MI Health Link, and Medicare policies and procedures, pharmacy formulary, and website changes.
8. Works closely with clinical services, claims, and transportation regarding authorizations, referrals, pre-notifications, benefit exceptions, and projects that benefit the organization.
9. Processes incoming release of protected health information documentation.
10. Facilitates routine and ad-hoc member outreach as directed by the customer service supervisor or manager.
11. Acts as back up to Receptionist as needed.
12. Supports National Committee for Quality Assurance (NCQA) Health Plan accreditation standards.
13. Maintains confidentiality of client data.
14. Performs other related duties as assigned.
POSITION QUALIFICATIONS:
Education:
Minimum:
High School Diploma
Preferred:
Some post-secondary education in health care or related field
Experience:
Minimum:
One (1) year of general customer service, sales, or medical office experience or equivalent
combination of education and experience
Preferred:
Two (2) to four (4) years of general customer service, call center, sales or medical office
experience or equivalent combination of education and experience
Required Skills:
Keyboarding proficiency
Working knowledge of MS Office (Word, Excel, and PowerPoint)
Digital dexterity
Exceptional customer service skills and telephone etiquette
Excellent human relation and oral/written communication
Excellent organization skills and attention to detail
Composition and proofreading abilities
Desirable Skills:
Oriented to managed care or health-care systems
Knowledge of medical terminology
The qualifications listed above are intended to represent the minimum skills and experience levels associated with performing the duties and responsibilities contained in this job description. The qualifications should not be viewed as expressing absolute employment or promotional standards, but as general guidelines that should be considered along with other job-related selection or promotional criteria.
Physical Requirements:
[This job requires the ability to perform the essential functions contained in the description. These include, but are not limited to, the following requirements. Reasonable accommodations may be made for otherwise qualified applicants unable to fulfill one or more of these requirements]:
Ability to access departmental files
Ability to enter and access information from a computer
Ability to access all areas of the UPHP offices
Moderate physical effort (lift/carry up to 25 pounds)
Occasionally lifts supplies/equipment
Prolonged periods of sitting
Manual dexterity and mobility
Working Conditions:
Works in office conditions
Fast-paced working environment
Subject to many interruptions
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