Please attach a cover letter describing why you are a great fit for this role, as well as your resume, when completing your submission for this opportunity.
GENERAL SUMMARY:
Responsible for addressing customer inquiries, grievances (complaints), identify appeals, process Individual plan cancellation requests, process deductible transfer requests while providing problem resolution and education via the HAP Web site (hap.org) Customer Message Center (CMC) and omni channels. Ensure adherence to established time frames to guarantee departmental, organizational and regulatory compliance. Communicate statistical data, trends and opportunities to proactively address member concerns and improve the customer experience.
PRINCIPAL DUTIES AND RESPONSIBILITIES:

• Provide investigation, follow-up and response to internal & external customer inquiries received from HAP's website, email, Pega Workbasket and all other omni channels.
• Work with leadership on escalated complaints to ensure timely follow-up, resolution, compliance and oversight. Include an investigation and analysis of the information and make a recommendation for appropriate course of action toward resolution.
• Generate custom and generic letters to internal and external customers in a prompt and courteous manner for all lines of business per departmental standards and internal/external guidelines.
• Make outreach phone calls to member to inform of the status of their inquiries and provide telephone support as needed.
• Respond to all incoming requests within 24 hours with an acknowledgement of receiving their case or a resolution.
• Provide leadership with statistical data to aid in process and performance improvement as it relates to internal and external inquiries. Identify, track and monitor trends and create analysis to ensure all regulatory requirements are met (NCQA, HIPAA, State, CMS etc.)
• Participate in continuous improvement initiatives and present findings.
• Assist in the development of communications to ensure website, email, Pega, and other omnichannel communications are current and reflect relevant brand and content.
• Attend meetings as required to gain knowledge of intra-departmental operations and gain knowledge of functional requirements for omnichannel.
• Maintain skills and training knowledge enhancements as needed to perform duties.
• Establish and maintain strong relationships and contacts across departments in addition to external contacts to ensure open communication, team effort and positive work relations.

E DUCATION/EXPERIENCE REQUIRED:

• Associate degree or 48 credit hours passed or four (4) years equivalent experience in related field.
• Two (2) years of demonstrated web/email-customer service, and/or other social media experience.
• Two (2) years of demonstrated problem resolution and root cause analysis which reflects the ability to handle escalated and or complex inquiries.
• Demonstrated experience and knowledge of various software programs, such as Windows, Microsoft Word, and Microsoft Excel.
• Demonstrated ability to compose business related written communication.
• Must demonstrate a very high degree of maturity, poise, flexibility and good judgment in responding to inquiries from customers.
• Must be dependable.
• Demonstrated problem solving, critical thinking, analytical and judgment skills.
• Work effectively with diverse people; strong interpersonal skills, using tact and diplomacy.
• Demonstrated verbal communication and strong business writing skills including creating and presenting presentations.
• Demonstrated ability to compose business related written communication.

EDUCATION/EXPERIENCE PREFFERED:

• Bachelor's Degree in Health Care, Business or related field of study preferred.
• Experience working in Pega Customer Relationship Manager/Appeal and Grievance preferred.
• A working knowledge of appeals, grievances, inquiries and the specific processes of how they should be processed preferred.
• Demonstrated experience in applying analysis and research techniques and experience in coordinating projects and obtaining results.
• Demonstrate the ability to organize, prioritize and handle multiple priorities concurrently in a timely and accurate manner with minimal supervision.
• Demonstrate the ability to handle assigned projects from start to successful completion including appropriate follow-up and documentation.
• Detailed understanding of HMO, PPO, Medicare, MMP, DSNP Medicaid, Qualified Health Plans through Health Care Reform, Self-funded and traditional health care delivery systems and benefits.
• Demonstrated technical understanding of database-oriented computer systems.
• Two (2) years of customer service experience in an office setting as a professional; health care preferred.