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Customer Service Representative I - Medicare
KEY RELATIONSHIPS:
Reports To: Supervisor, Medicare Operations Customer Service
Supervises: None
Other Key Relationships: Plan members and providers
FLSA: Non-Exempt
Job Code: MF5004
POSITION PURPOSE:
Responds to member and provider inquiries regarding benefits, eligibility, status of claims, and other related issues in an effort to provide information and facilitate and/or coordinate appropriate resolutions.
PRINCIPLE DUTIES:
- Responds accurately and courteously to member and provider inquiries regarding benefit interpretation, eligibility, claims status, accessing care through plan providers, and other related issues Medicare Advantage Plans and on occasion, other products as offered by the Community Health Plan.
- Provides information and facilitate and/or coordinate appropriate resolution of issues and complaints.
- Documents inquiries, complaints, phone hospital notifications, and other data in computer database in an accurate, clear, and timely manner.
- Provides back-up as needed to other positions and functional areas such as Eligibility and Referrals.
- Provides first call resolution at established standards.
- Actively participates in developing and maintaining a cohesive customer service team that is focused on providing excellent customer service.
- Establishes and maintains good working relationships with others in the organization.
- Participates as needed in special projects such as enrollment fairs, telephone surveys, new-hire training, etc.
- Meets CS attendance and quality standards. Makes a consistent effort to learn and improve CS skills as measured by the quality of the phone work.
- Other duties assigned.
OTHER ESSENTIAL FUNCTIONS:
Being able to report to work on time and work the days scheduled is important to this position.
QUALIFICATIONS:
Education:
- High school diploma or equivalent required.
- Some college or vocational training preferred.
Prior Related Experience:
- 1-2 two years customer service experience preferred, insurance, managed care, or provider setting.
- Experience in a call center environment strongly preferred.
- Experience with medical insurance such as Medicare Advantage Plans a plus.
Employment Eligibility:
Candidate has not been sanctioned or excluded from participation in federal or state healthcare programs by a federal or state law enforcement, regulatory, or licensing agency.
Knowledge, Skills, and Abilities:
- Ability to meet scheduled deadlines with minimal supervision.
- Strong organizational skills and accurate work results.
- Ability to maintain a professional demeanor and confidentiality
- Excellent customer service skills including the ability to work with people with diverse needs in a respectful and courteous manner at all times.
- Demonstrated oral communication skills including the ability to convey complex information in a way that is easily understood by the member.
- Demonstrated written communication skills particularly the ability to summarize notes in a clear, concise manner.
- Ability to identify and solve problems creatively and with flexibility.
- Ability to prioritize, organize, and complete daily work both independently and with team members.
- Computer literate and proficient in Microsoft Word or other word-processing programs.
- Type 35 wpm.
- Ability to maintain a professional demeanor and confidentiality in behavior and dress.
- Ability to cope well under stressful situations.
- Knowledge of medical terminology and healthcare is preferred.
- Knowledge of medical insurance and/or Medicare Advantage Plans preferred.
- Language skills, particularly in Spanish, a plus.
SENSORY/PHYSICAL/MENTAL REQUIREMENTS
Speaking, hearing, near vision, far vision, depth perception, peripheral vision, touch, smell, and balance.
Physical:
Extended periods of sitting, computer use, talking and possibly standing.
Simple grasp, firm grasp, fine manipulation, pinch, finger dexterity, supination/pronation, wrist flexion. Frequent torso/back static position; occasional stooping, bending and twisting. Some kneeling, pushing, pulling, lifting and carrying (not over 25 pounds), twisting and reaching.
Mental:
Frequent decision-making. Ability to gather and assess data, determine appropriate actions, apply protocols and knowledge to unique situations, problem-solve and provide consultation.
WORK ENVIRONMENT
Office environment with frequent environmental exposure to low-grade radiation from computer monitors; fast paced with frequent interruptions.
PROTECTED HEALTH INFORMATION (PHI) ACCESS
Community Health Plan employees will encounter protected health information in the regular course of their work at and for Community Health Plan. Community Health Plan is a Covered Entity engaging in Health Care Service Contractor treatment, payment and operations. The following scale intends to provide some indication of how often the employee may encounter or work with PHI in this particular role. All PHI shall be used and disclosed on a Need To Know Basis and according to HIPAA Privacy Rules Part 164. In addition, every employee shall sign a confidentiality agreement as a condition of employment and violation of that agreement and/or Community Health Plan policies can be cause for termination.
PHI is defined at 164.103 as:
"Protected health information means the individually identifiable health information that is (i) Transmitted by electronic media; (ii) Maintained in electronic media; (iii) Transmitted or maintained in any other form or medium.
Individual means the person who is the subject of protected health information.
Individually identifiable health information is information that is a subset of health information, including demographic information collected from an individual, and:
(1) Is created or received by a health care provider, health plan, employer, or health care clearinghouse; and
(2) Relates to the past, present, or future physical or mental health or condition of an individual; the provision of health care to an individual; or the past, present, or future payment for the provision of health care to an individual; and
(i) That identifies the individual; or
(ii) With respect to which there is a reasonable basis to believe the information can be used to identify the individual.
This position as described will use, encounter, read, create, disclose and or work with in general, PHI that is created by or received by Community Health Plan:
Frequent - The position has frequent and/or daily access and responsibility for PHI. Need to know.
In all cases, PHI use and disclosure is limited to the minimum necessary amount of PHI needed to complete the treatment, payment or operations.
The above is intended to describe the general content of and the requirements for satisfactory performance in this position. It is not to be construed as an exhaustive statement of the duties, responsibilities or requirements of this position.
