Member Services Representative - Work From Home

Description:
MUST be listed at top of resume; will be rejected if the following is not provided.
- internet speed test at top of resume; needs to have a minimum speed of 25 MBPS/3 MBPS
- Does this candidate have hardwired connection/ ethernet connect? Yes or no
- Can this candidate attend all training as scheduled; 3 week training process; 8AM-5PM M-F CST
- MUST live in Oklahoma, but 100% remote
MAX Bill Rate: $32.19
Front line customer service inbound call center representative (telephonic-no sales) assisting members, prospective members and providers with questions regarding benefits, pharmacy services, provider listings, etc. in a high volume, fast paced, call center environment. Must have reliable internet, with a minimum speed requirement of 25 mbps/ 3mbps.A hardwired connection is required (ethernet connection); a wireless connection will introduce the risk of performance degradation. Must attend all training as scheduled.
Duties
Answers questions and resolves issues based on phone calls/letters from members, providers, and plan sponsors. Triages resulting rework to appropriate staff.
Documents and tracks contacts with members, providers, and plan sponsors. The CSR guides the member through their members plan of benefits, Healthcare policy and procedures as well as having knowledge of resources to comply with any regulatory guidelines.
Creates an emotional connection with our members by understanding and engaging the member to the fullest to champion for our members' best health.
Taking accountability to fully understand the member's needs by building a trusting and caring relationship with the member.
Anticipates customer needs. Provides the customer with related information to answer the unasked questions, e.g. additional plan details, benefit plan details, member self-service tools, etc.
Uses customer service threshold framework to make financial decisions to resolve member issues.
Explains member's rights and responsibilities in accordance with contract.
Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievance and appeals (member/provider) via target system.
Educates providers on our self-service options; Assists providers with credentialing and recredentialing issues.
Responds to requests received from Healthcare's Law Document Center regarding litigation; Lawsuits.
Handles extensive file review requests.
Assists in preparation of complaint trend reports. Assists in compiling claim data for customer audits.
Determines medical necessity, applicable coverage provisions and verifies member plan eligibility relating to incoming correspondence and internal referrals.
Handles incoming requests for appeals and pre-authorizations not handled by Clinical Claim Management.
Performs review of member claim history to ensure accurate tracking of benefit maximums and/or coinsurance/deductible. Performs financial data maintenance as necessary.
Uses applicable system tools and resources to produce quality letters and spreadsheets in response to inquiries received.
Experience
High School or GED equivalent.
Customer Service experiences in a transaction-based environment such as a call center or retail location preferred, demonstrating ability to be empathetic and compassionate.
Experience in a production environment.
Position Summary
Responsible for increasing member and provider satisfaction, retention, and growth by efficiently delivering competitive services to members and providers through a fully integrated organization staffed by knowledgeable, customer-focused professionals supported by exemplary technologies and processes. Customer Service Representative is the face of Healthcare and impacts members' service experience by manner of how customer service inquiries and problems via telephone, internet or written correspondence are handled. Customer inquiries are of basic and at times complex nature. Engages, consults and educates members based upon the member's unique needs, preferences and understanding of Healthcare plans, tools and resources to help guide the members along a clear path to care.
Education
High School or GED equivalent.
What days & hours will the person work in this position? List training hours, if different.
Between 8am - 5pm M-F