[Remote] Customer Care Representative I - SHP Customer Service - Telecommuter - Day Shift - Full Time

Note: The job is a remote job and is open to candidates in USA. Sharp HealthCare is seeking a Customer Care Representative I to facilitate communication between the Plan and its members, providers, and other stakeholders. This role involves providing information about Plan products, resolving concerns, and maintaining accurate records of customer interactions.

Responsibilities

• Responsible for direct and timely communication between the Plan and Plan members, potential members, providers, employer groups, brokers, internal departments and external agencies
• Maintains high level of knowledge regarding Plan products, premiums, benefits and procedures
• Uses knowledge and judgment to select appropriate resources for assisting callers
• Provides information on all aspects of Plan products, premiums, benefits, policies and procedures
• Responsible for accurate problem-solving
• Researches and resolves concerns
• Access patient data Documents all calls in the IDX Customer Service Module immediately
• Verifies prescription drug eligibility, benefits, claims, and authorizations in PBM's MedAccess system
• Adds and updates member information in the MedAccess system
• Maintains current knowledge of IDX system modules for Registration, Enrollment, Claims, Utilization Management and Premium Billing
• Verifies enrollment, benefits premiums and other individual and group information in Salesforce
• Generates member letters using Globalworks
• Retrieves member documents stored in OnBase
• Uses SharpConnect to assist members with online inquires
• Ability to understand and resolve common Commercial member inquires/complaints by phone
• Provides prompt, accurate and excellent services to internal and external customers
• Develops solid professional working relationships with various internal departments and units and, as required, vendors, providers, employers, brokers and/or other customers
• Works collaboratively with other Plan and medical group departments to address customer questions and concerns, including Health Services, Enrollment, Claims Research, Underwriting
• Works collaboratively with health care providers and office staff to facilitate access to care
• Maintains a complex and evolving knowledge of health insurance and health care reform mandates
• Participates in special projects and other duties as assigned
• Assists new and existing members in attaining a workable understanding of their health coverage, clarifies terminology in enrollment materials, and instructs members regarding how to utilize the services of the Plan and the provider network
• Answers inquiries from potential members, members, brokers, employer groups, State and County representatives, Plan providers, internal departments, and all other callers, including: a) Verification of eligibility, enrollment and PCP assignment; b) Benefit, co-payment, and referral questions; c) Requests for PCP changes, address changes, ID cards, benefit materials; d) Inquiries regarding premium and subsidy amounts and balances; and e) Clarification of conversion, COBRA, and Cal-COBRA enrollment procedures, including quotes of approximate rates
• Documents member concerns, complaints, and appeals, and forwards to the appropriate Customer Care Lead or Supervisor on a daily basis
• If unable to provide immediate assistance, promptly returns calls with answers and resolutions
• Utilizes appropriate handbooks, Evidence of Coverage, supplemental benefit information, and other reference material as needed to quote Plan benefits, exclusions, and policies
• Maintains detailed knowledge of required materials and resources, including: a) Operations policies and procedures b) All Combined Evidence of Coverage (Member Handbooks) and Employer Group Benefit Agreements c) Language Line
• Informs and works collaboratively with other Plan departments, in areas including but not limited to: a) Forwarding prospects for new brokers or employer groups to Marketing; b) Working with Health Services regarding authorization requests and assistance for special need cases; c) Forwarding potential provider education issues to Provider Relations; d) Documenting potential member fraud, COB, and third party liability issues, and reporting to the appropriate department; and e) Documenting requests for additions to the provider network and forwarding to Contracting
• Assists members with premium and billing questions
• Processes ACH and credit card payments over the phone
• Uses appropriate resources to describe and recommend plan options to individuals interested in purchasing Sharp Health Plan coverage
• Identifies and recommends solutions for operational problems to ensure continued high quality service to internal and external customers
• Maintains an organized work area
• Effectively utilizes a wide range of reference materials
• Demonstrates knowledge of specific enrollment, benefit, and premium information for commercial (group and individual) and Medicare products
• Complies with regulatory and accreditation requirements and timelines for customer service including DMHC, CMS, and NCQA
• Works with moderate supervision on projects assigned by Customer Care Supervisor, including but not limited to: New member orientation; Premium billing reminders and payment processing; Member education; Member claims investigation and resolution; Pharmacy prior authorizations and eligibility; Member appeal/concern investigation and documentation; Member reimbursement requests
• Maintain overall scorecard score of 3.0 or higher for 6 consecutive months
• Meet or exceed in all scorecard metrics for 6 consecutive months
• Behavior Standards - Average Score of 8 or higher within a 12 months period
• Attendance - No more than 2 unscheduled occurrences within a 12 months period
• Knowledge - Customer Care Commercial Knowledge Assessment score of 80% or above

Skills

• H.S. Diploma or Equivalent
• Less Than 1 Year Minimum of six (6) months experience as a Customer Call Center Representative
• Associate's Degree Business administration or health care administration (including courses of study in accounting, finance, marketing, and health care administration)
• 2 Years Customer service or medical office experience
• 1 Year Experience working full time as SHP Customer Care Temporary CCR I
• Medical office certification, to include medical terminology, preferred
• Bilingual preferred but not required

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