Customer Care Representative – Customer Service

Job Requirements

POSITION SUMMARY

The Customer Care Representative applies knowledge and sound communication skills to investigate and independently resolve telephone and in-person inquiries from customers and providers regarding health benefits, claims, authorizations, prescriptions, providers, eligibility, enrollment, and any other plan-related questions. The Customer Care Representative will make each interaction effortless by creating forward-moving, solution-oriented conversations and providing complete and accurate solutions for an easy, enjoyable, and seamless customer experience.

PRIMARY ACCOUNTABILITIES

1. Builds customer loyalty and trust by being a solution-minded advocate who educates, empowers, and supports our customers throughout their Health First wellness journey.
2. Guides customers through their inquiries to successful resolution by actively listening, creating two-way conversations, and utilizing critical thinking.
3. Recognizes the customer’s initial inquiry and proactively identifies any underlying or unspoken needs by asking probing questions to guide the customer through any complex issues.
4. Offers each customer a personalized solution and time frame to meet their needs. Provides alternative options, adhering to applicable department policies, when a customer’s preferred resolution is not available.
5. Supports fellow associates and models excellence in service behavior for customer inquiries.
6. Supports and assists with customer requests for benefit, reimbursement, or plan documents to be sent via mail, fax, and email, while exercising advanced knowledge of HIPAA guidelines.
7. Assists with customer service walk-in members in a timely and efficient manner.

Work Experience

MINIMUM QUALIFICATIONS

• Education: High School/GED
• Licensure: None
• Certification: None
• Work Experience: One (1) plus years of experience as a HFHP Customer Care Associate
• Work Experience in lieu of Education: None
• Knowledge/Skills/Abilities:
• Demonstrated knowledge and understanding of prescription drug coverage concepts, eligibility, coverage, claims, and payment provisions. 
• Demonstrated knowledge and understanding of processes and procedures for member appeal and grievance rights including coverage determination, and organization determinations.
• Demonstrated proficiency with core applications, including Health First Health Plans’ administrative, pharmacy, utilization management, claims, enrollment, and payment systems, Microsoft applications, and member, broker, and provider portals.
• Knowledge of Health First Health Plans’ call center and administrative operations.
• Excellent verbal, written, and interpersonal communication skills that model I-CARE values and consistently provide a seamless and delightful customer experience.
• Demonstrated consistency with achieving productivity and quality metrics.

PREFERRED QUALIFICATIONS

• Education: Bachelor’s degree in business, Health Care Administration, or related field from an accredited college or university.
• Work Experience: Coaching experience in a customer service environment.

PHYSICAL REQUIREMENTS

• Majority of time involves sitting or standing; occasional walking, bending, stooping.
• Prolonged periods of computer time or at workstation.
• Light work that may include lifting or moving objects up to 20 pounds with or without assistance.
• May be exposed to inside environments with varied temperatures, air quality, lighting and/or low to moderate noise.
• Communicating with others to exchange information.
• Visual acuity and hand-eye coordination to perform tasks.
• Workspace may vary from open to confined; on site or remote.
• May require travel to various facilities within and beyond county perimeter; may require use of personal vehicle.

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