The Customer Service Representative communicates with a diverse constituency of internal and external customers and responds to individual questions and concerns specific to organizational determinations, claims, plan benefits, coverage determinations, disputes, and questions or issues related to payment methodology. Receives and responds to calls from providers and members. Transfers calls as necessary to applicable department, such as, but not limited to, utilization management, or to applicable Health Plan as appropriate. Conducts inquiries and research related to provider and member questions and concerns, including claims and authorization status and related information, and documents all calls and responses. Relays plan contact information to providers and members as applicable and appropriate.
- Receives inbound calls and responds appropriately to provider, or member, questions and/or concerns.
- Answers calls timely and in accordance with the performance standards established within the customer service department.
- Provides information as requested related to coverage determinations and appeals processes.
- Provides information as requested by caller related to claims and authorizations.
- Facilitates provider and member communications related to network providers.
- Responds to provider dispute queries.
- Provides plan contact information as applicable to members and providers.
- Facilitates communication through the Language Assistance Program (for members who are not English proficient) of the various plans, and/or arranges for interpreter, including interpretive services for the hearing impaired.
- Maintains applicable and timely records and files regarding member and provider communications and service coordination.
- Reviews all documents received for completeness, verifies eligibility member
- Verifies claims status and coordinates information, as applicable, with provider and claims staff.
- Forwards calls as appropriate to supervisor or other staff for further response or follow up.
- Ensures confidentiality of all hard copy, electronic, and verbal communication, and adheres to organization’s policies related to privacy and disclosure.
- Promotes a positive image of the organization and the department in all aspects of communication and contact.
- Performs other duties as assigned.