Purpose:

The Customer Service Representative is an integral member of the Claims, Medical Management and Priority Care Center teams. They provide first line customer service, clerical support, schedule appointments and process authorizations as directed. This is a full-time benefited position. Starting wage range $18.00 - $23.00 per hour.

Responsibilities:

Overall: Customer service employees are responsible for providing excellent customer service and complying with policy service standards. Customer service staff is available from 8:00 am to 4:30 pm on business days to answer questions from providers, members and patients.

Customer Service:

• First Line Customer Service resolution. First-line services are requests initiated by fax, telephone or walk in contact with a CSR, which after contact is initiated, can be reasonably resolved by that agent. Occasionally these service requests will require some research prior to resolution.
• Second Line Customer Service. Second-line services are services initiated by a fax, telephone or walk in communications to a CSR, which require consultation with a department manager prior to resolution

• Types of services include:
• Taking messages and scheduling appointments for the Priority Care Center

• Health plan eligibility Benefit eligibility, availability, and clarification
• Authorization status and tracking
• IPA Policy and Procedure clarification
• Claims status, tracking and adjudication requests
• Provider quality of care complaints

• Documentation of all customer interactions.

Clerical Support:

• PDR tracking and routing
• Assist RN care managers as needed to effectively process authorizations and provide case management.
• Produce and distribute TAT (turn around) reports daily.
• Produce customer service and authorization volume reports weekly. Analyze and correct errors as needed.

Medical Management Support:

• Enter authorizations into EZ-Cap upon receipt.
• Process and/or prepare authorizations for decision-makers per policy and procedure.
  • Verify benefits and/or eligibility
  • Verify provider status, i.e. in-network/contracted, etc.
• Send notifications to members, providers and health plans per policy and procedure.
• Maintain timeframes for each step of the authorization process.

Other Projects and Duties As Assigned

Qualifications:

• Medical office or related experience.
• Basic knowledge of CPT, HCPCS and ICD10 coding.
• Excellent communication and customer service skills.
• Strong computer skills.

Characteristics:

• Well organized, efficient, and detail oriented.
• Demonstrates effective communication skills with all types of customers.
• Participates well as part of a work team.
• Ability to work on multiple issues at a time and follow through to resolve them.
• Follows detailed instructions and works with minimal supervision.

Maintains a positive attitude and professional demeanor at all times