_POSITION SUMMARY _

Responsible for providing quality, professional service to all customers when calls are received through the Member Services Department via telephone, written or in-person in accordance with Plan guidelines.

***Compensation starting at $18/hr. and based on experience ** Bilingual in Creole Required

ESSENTIAL DUTIES & RESPONSIBILITIES

Responsibilities include but are not limited to:

Handles telephone, written and in-person inquiries in a courteous, professional, thorough, and timely manner to assure member satisfaction.

• Assists callers on inquiries regarding coverage decisions, grievances, appeals, benefit interpretation, eligibility verification, medical group/PCP, explanation of how the plan works and how to utilize services, assists with information regarding referrals or authorizations, member complaints, identification card requests.
• Responsible for maintaining customer service levels (abandonment rate, speed of answer and service level) within established parameters.
• Knowledge on plans benefit, CMS and Plans policies and procedure.
• Applies high level of subject matter knowledge to solve a variety of common business issues.
• Provides quality services effectively to increase the overall level of customer service and satisfaction as measured by CMS.
• Identifies the differences between a Grievance, Appeal or Coverage Decision and process the request through the appropriate channels.
• Identify, handle, document and/or route Utilization Management inquiries appropriately
• Identify and document Coverage Determinations. ( all incoming calls)
• Record all inquiries and complaints.
• Requests various brochures and forms to members at their request.
• Interacts with other departments about member issues or concerns.
• Approaches work in a meticulous and thorough manner, pays attention to detail and follows company scripts.
• Is attentive to the callers needs, and responds quickly and competently to requests.
• Keeps files and work area organized.
• Manages time effectively and prioritizes tasks to meet deadlines.
• Is flexible and can adjust to shifting priorities.
• Communicates effectively with other professional and support staff in order to achieve positive customer outcomes.
• Promotes and contributes to a positive, problem-solving environment.
• Assists customers, family members and others with concern and empathy; respect their confidentiality and privacy and communicate with them in a courteous and respectful manner.
• Complies with company policies and procedures and maintains confidentiality of customer medical records in accordance with state and federal laws.
• Ensures compliance with all HIPAA, OSHA, and other federal, state and local regulations.
• Participates in meetings, trainings and in-service education, as required.
• Performs all other duties as assigned.

QUALIFICATIONS & EDUCATION

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.

• Minimum of High School diploma or equivalent
• 2 years call center, healthcare, or related field experience
• An educative approach to answering questions and informing people of health plan policies, procedures, or decisions.
• Ability to read, analyze, and interpret technical procedures or governmental regulations
• An educative approach to answering questions and informing people of health plan policies, procedures, or decisions.
• Excellent communication skills, attention to detail, ability to set priorities appropriately and meet strict deadlines and the ability to manage multiple tasks simultaneously is required
• Must have demonstrated experience with Microsoft Office Suite (Outlook, Word, Excel, Power Point, etc.)
• Familiarity with healthcare laws, regulations and standards
• Must be patient in dealing with an elderly population and sympathetic to hearing or vision deficiencies
• Ability to work effectively independently, work with very little supervision and in a team environment
• Ability to effectively present information and respond to questions from groups of managers, clients, customers and the general public
• Ability to define problems, collect data, establish facts, and draw valid conclusions
• Strong decision-making, analytical skills
• Must be self-motivated, organized and have excellent prioritization skills
• Must be able to work well under stressful conditions
• Must be able to work in a fast paced environment
• Must be able to work weekends and evening shifts.
• Bilingual (preferably in English and Spanish)

PREFERRED:

• 2 years Medicare Advantage Plan customer service experience
• Working knowledge of Medicare Advantage, medical terminology and HIPAA guidelines
• Bilingual

PERFORMANCE MEASUREMENTS

• 3-5 Monthly evaluations
• Compliance with Department Call Metrics/ Company Regulations
• Attendance/Punctuality

Safety and Security Quality of work

This Job Description may be modified at any time at the discretion of the employer as business operation may deem necessary. This does not constitute an employment agreement and may not include all duties.

The above statements are intended to describe the general nature and level of work being performed by individuals assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required of personnel so classified. The incumbent must be able to work in a fast-paced environment with demonstrated ability to juggle and prioritize multiple, competing tasks and demands and to seek supervisory assistance as appropriate.