About The Role

is not intended to be all-inclusive; employees will perform other reasonably related business duties as
assigned by the immediate supervisor and/or health plan administration, as required.

General Duties

Assist members and providers by responding to telephone inquiries in a prompt, accurate and objective manner regarding but not limited to:
o Abuse, Neglect and Exploitation
o Authorizations
o Behavioral Health
o Claims
o Complaints
o Crisis Calls
o Eligibility
o Health Insurance Benefits
o Locating providers
o Pharmacy Benefits
o Transportation
o Waste Abuse and Fraud

90% of the scheduled time on the phone according to business needs.
Drives resolution of caller questions/issues on the first call whenever possible and ensures proper documentation of calls and resolution actions.
Understand and adhere to HIPAA requirements.
Adhere to Regulatory Guidelines and policies & procedures.
Navigating through complex computer systems to identify the status of the issue and provide appropriate response to caller.
Review previous call interactions/notes.
Communicate monthly messages to members and providers on a specific need basis.
Deal tactfully and empathetically with members and providers.
Establish and maintain effective working relationships with provider office staff.
Read, comprehend, and verbalize processes and procedures of the organization and of health insurance coverage.
Multi-task by utilizing multiple complex computer applications.
Pay close attention to detail.
Identify issues/trends and escalate to Supervisor / Manager when assistance is needed.
Develop relationships with other departments to provide feedback about root cause issues.
Intervene with providers on behalf of the customer to assist with appointment scheduling or connections with specialists for assistance when needed.
Assist customers in navigating through the Driscoll Health Plan website and encourage and reassure them to become self-sufficient.
Own problem through to resolution on behalf of the customer in real time or through comprehensive and timely follow-up with the member and or provider.
Research complex issues across multiple databases and work with internal departments to resolve customer issues and/or partner with others to resolve escalated issues.
Other duties as assigned.

EDUCATION AND/OR EXPERIENCE

Minimum of a high school diploma or equivalent
Customer service experience
Experience working in a call center or healthcare related field is a plus
Strong customer service skills, including courteous telephone etiquette and professionalism
Prior understanding and awareness of call center metrics and goals preferred
Prior healthcare experience, in particular, Medicaid Insurance Plans preferred
Ability to type a minimum of 35 words per minute
Knowledge of managed care processes and health insurance coverage preferred
Knowledge of medical terminology preferred
Outstanding communication skills and the ability to understand complex situations to effectively handle escalated customer needs
Analytical skills and the ability to read and interpret data
Problem solving abilities
Ability to work independently and as a part of a team
Ability to operate computer programs – Proficiency with Microsoft Office applications, particularly Outlook, Word, and MS Teams