Where compassion meets innovation and technology and our employees are family. Thank you for your interest in joining our team! Please review the job information below. $3,500 Sign-on Bonus Offered! GENERAL PURPOSE OF JOB: The Customer Service Representative is responsible for the assisting Member/ Provider with healthcare inquires concerns, or complaints via telephone. ESSENTIAL DUTIES AND RESPONSIBILITIES: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This job description is not intended to be all-inclusive; employees will perform other reasonably related business duties as assigned by the immediate supervisor and/or health plan administration, as required. General Duties: Assist members and providers by responding to telephone inquiries in a prompt, accurate and objective manner regarding but not limited to: o Abuse, Neglect and Exploitation o Authorizations o Behavioral Health o Claims o Complaints o Crisis Calls o Eligibility o Health Insurance Benefits o Locating providers o Pharmacy Benefits o Transportation o Waste Abuse and Fraud • 90% of the scheduled time on the phone according to business needs. • Drives resolution of caller questions/issues on the first call whenever possible and ensures proper documentation of calls and resolution actions. • Understand and adhere to HIPAA requirements. • Adhere to Regulatory Guidelines and policies & procedures. • Navigating through complex computer systems to identify the status of the issue and provide appropriate response to caller. • Review previous call interactions/notes. • Communicate monthly messages to members and providers on a specific need basis. • Deal tactfully and empathetically with members and providers. • Establish and maintain effective working relationships with provider office staff. • Read, comprehend, and verbalize processes and procedures of the organization and of health insurance coverage. • Multi-task by utilizing multiple complex computer applications. • Pay close attention to detail. • Identify issues/trends and escalate to Supervisor / Manager when assistance is needed. • Develop relationships with other departments to provide feedback about root cause issues. • Intervene with providers on behalf of the customer to assist with appointment scheduling or connections with specialists for assistance when needed. • Assist customers in navigating through the Driscoll Health Plan website and encourage and reassure them to become self-sufficient. • Own problem through to resolution on behalf of the customer in real time or through comprehensive and timely follow-up with the member and or provider. • Research complex issues across multiple databases and work with internal departments to resolve customer issues and/or partner with others to resolve escalated issues. • Other duties as assigned. EDUCATION AND/OR EXPERIENCE: • Minimum of a high school diploma or equivalent • Customer service experience • Experience working in a call center or healthcare related field is a plus • Strong customer service skills, including courteous telephone etiquette and professionalism • Prior understanding and awareness of call center metrics and goals preferred • Prior healthcare experience, in particular, Medicaid Insurance Plans preferred • Ability to type a minimum of 35 words per minute • Knowledge of managed care processes and health insurance coverage preferred • Knowledge of medical terminology preferred • Outstanding communication skills and the ability to understand complex situations to effectively handle escalated customer needs • Analytical skills and the ability to read and interpret data • Problem solving abilities • Ability to work independently and as a part of a team • Ability to operate computer programs – Proficiency with Microsoft Office applications, particularly Outlook, Word, and MS Teams