Customer Service Representative

Job Description: POSITION SUMMARY: The Customer Care Representative is devoted to providing effective customer service and issue resolution to all callers. This position works within a team oriented, call-center environment to accomplish department goals. ESSENTIAL DUTIES AND RESPONSIBILITIES: Answers inbound member and provider calls related to health plan questions.Ascertains the reason for the call and assists the customers with their questions or concerns in a manner that provides them with immediate and accurate information, focusing on first call resolution. Follows up with customers when first call resolution is unachievable. · Coordinates with other departments to effectively resolve the customers’ concern or complaint. · Adheres to department policy and procedures including but not limited to call statistics, goals, and department deadlines.Responds to and completes Web/electronic/mailed Member inquiries.Completes overflow and after-hours Member calls known as Ask Customer Service (ACS) inquiries. · Assists in compiling and mailing Member packets · Assists in outbound test calls to Interpreters and TTY/TDD · Obtain a mastery level knowledge of assigned specialty line of business (LOB) · Assists with the Customer Loyalty Management (CLM) and Primary Care Physician (PCP) programs. · Assists in Member outbound retention calls · Assists with department audits · Assists in the handling of Complaints, Appeals, and Grievances · Assists with incoming calls during extended hours (Monday through Friday 5 PM – 8 PM and Saturday – Sunday 8 AM to 8 PM), if volunteers are unavailable. · Must maintain confidentiality of business information, including Protected Health Information (PHI), as required by HIPAA and company policy.Other duties as assigned EDUCATION AND EXPERIENCE: Education Required: · High school diploma or GED required · Some completed college courses in health care, business or related field preferred. Years and Type of Experience Required: · 3 years of customer service experience in a call-center environment and/or experience in healthcare or insurance industry required · Computer proficiency with MS Office Suite (Word, Outlook, Excel) · Previous experience in a fast-paced call center, managed care environment and/or Medicaid and/or Medicare focused position preferred · Basic knowledge of Medical Claims and terminology preferred KNOWLEDGE, SKILLS AND ABILITIES: Exceptional customer service skills including effective and efficient problem solving and analyzing skillsRequires excellent active listening and oral and written communication and grammar skills.Ability to facilitate conversations with others and establish an understanding of the customer's issue/reason for contactAbility to perform essential job functions with high degree of independence, flexibility, and creative problem-solving techniquesAbility to maintain control of the call by de-escalating issues and instilling confidence that the resolution has been found.Ability to function effectively under stress of conflicting demands on time and attention and, sometimes, under duress from difficult personalitiesAbility to multi-task, set priorities, and manage time effectivelyAbility to maintain a positive attitude.Maintains a professional and respectful relationship with all coworkers, vendor representatives, supervisors, managers, customers, and client representatives. WORK ENVIRONMENT: The work environment is within a fast-paced call center with a requirement to be talking on the phones 80% or more of the work day. TRAVEL: This position does not require work travel. SUPERVISORY RESPONSIBILITY: This position does not contain Supervisory responsibilities. OTHER DUTIES: This job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.