The Customer Service Representative (CSR) is the first line of contact for CalOptima members and providers. The incumbent will assist members and providers with questions related to the Medi-Cal programs for Orange County. Resolves member inquiries and complaints fairly and effectively. This position will provide information regarding eligibility, enrollment, benefits and services to CalOptima eligible members and providers.
POSITION RESPONSIBILITIES:
- Addresses member inquiries, questions and concerns in all areas including enrollment, claims, benefit interpretation, and referrals/authorizations for medical care.
- Verify member eligibility, claim and authorization status for providers.
- Responsible for thorough follow-up and completion of all member, and provider inquires or requests
- Responsible for accurate, complete and correct documentation into Facets regarding all issues, and/or inquires, complaints and grievances.
- Function efficiently and productively in a high-volume telephone call center.
- Maintain departmental productivity and quality standards.
- Provide follow-up assistance as needed.
- Route escalated calls to the appropriate Member Liaison, Supervisor or Call Center Manager
- Refer issues to health networks and/or make recommendations for further contacts within CalOptima.
- If designated, responsible for processing all member transportation request within 1 business day of receipt and coordinating all aspects of the process with clinic, provider and member as appropriate or necessary
- Adhere to company and departmental policies and procedures.
- • Assists Members with CalOptima’s Member Web Portal registration and technical support. Other duties or projects as assigned by management.
Required Skills
- Establish and maintain effective interpersonal relationships with members, coworkers and the public.
- Function efficiently and productively in a high-volume telephone call center.
- Effectively communicate both in writing and verbally.
- Learn procedures and regulations governing member eligibility and the terminology and documents used while remaining knowledgeable of CalOptima/Medi-Cal benefits and procedures.
- Understand and follow oral and written directions.
- Hear and speak well enough to converse on the telephone and in person.
- Perform work requiring repetitive use of hands, arms or shoulders (e.g. keyboarding, typing, etc.).
- Effectively utilize computer and appropriate software and interact as needed with CalOptima Information Systems.
Required Experience
EXPERIENCE & EDUCATION:
- High school diploma or equivalent required.
- 6 months call center experience with high call volumes or customer service experience analyzing and solving customer problems required. HMO, Medi-Cal/Medicaid and health services experience preferred.
- Bilingual in English and in one of CalOptima's defined threshold language is required.
KNOWLEDGE OF:
- Principles and practices of managed health care, health care systems, and medical terminology.
- Principles and techniques for handling customer service issues.
- Personal computers, keyboarding, and appropriate software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.
- Understanding of the CalOptima program.
- Customer service principles and practices.
Grade: H