Customer Service Rep

Folsom, CA

Post Date: 09/20/2017 Job ID: 2708867 Industry: Customer Service Representative
Function as the front-line contact for all members by responding to a high-volume of incoming calls from members and prospective members.Respond accurately to provider calls related to PT-1 status, transportation guidelines, member eligibility and managed care status, prior authorization, and pharmacy guidelines and procedures.Provide members with all current MCO options available to promote member choice within the assigned network or managed care providers, using knowledge gained through training and other sources.Accesses, reads and interprets intranet, client and provider data elements on all systems, including MMIS, MA-21 and MassServe.Copes with the stress of high call volume or emotionally charged encounters by approaching each call with level- headedness, compassion and empathy.Communicates with Supervisor regarding any potential needs or concerns.Assists in educating and instructing members on routine policy matters such as, and not limited to: eligibility and enrollment, claims and premium billing, managed care, covered services, transportation and special programs. Uses each encounter as an opportunity to educate Members on all available tools, such as self-service options, to reduce their administrative work efforts.Provides members with all current MCO options available to promote members choice within the assigned network of managed care providers.Ensures that Protected Health Information (PHI) is not released to otherwise unauthorized persons, unless that release is consistent with the wishes expressed on the Permission to Share Information (PSI) Form.Documents and tracks all Member contacts and activities using MassServe, including; provider number, member identification number, contract reason, contract outcome and any other information required to ensure further encounters are productive.Participates in setting and meeting department goals and meets all individual standards established of the position.Participates in special projects or continuous Quality Improvement initiatives as neededConducts a thorough health care need assessment with members, including existing and anticipated needs of all eligible family members, as needed.Investigates all third party resources and complies with systems and administrative requirements.Performs, accurately, all data entry functions to reflect member or provider activity-/transactions.Facilitates the resolution of non-clerical issues related to member compliance/participation according to established polity and protocols.Conducts all interactions with members and providers in a discreet, courteous and professional manner.Performs other duties as may be assigned by management.

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