Clinical Member Services Agent

Southern Scripts•Baton Rouge, LA

About The Position

The clinical member services agent (CMSA) is responsible for providing effective customer service for all internal and external customers by using excellent, in-depth knowledge of company products and programs as well as communicating effectively with team members within the clinical department. The CMSA will work in conjunction with the member service agent to assist in clinical situations and resolutions. Knowledge of principles and processes for providing customer and personal services. This includes customer needs assessment, meeting quality standards for services, and evaluation of customer satisfaction. Confer with customers by telephone to provide information about Rx claims processing. Understanding of Pharmacy terms and formularies as a certified Pharmacy Technician (CPhT). Keep detailed records of customer interactions or transactions, recording details of inquiries, complaints, or comments, as well as actions taken. Follow-up to ensure that appropriate changes were made to resolve customers' problems. Refer unresolved customer grievances to designated departments for further investigation. Review Rx insurance policy terms to determine whether a claim is covered for employer group. Contact customers to respond to inquiries or to notify them of claim investigation results or any planned adjustments. Resolve customers' service or billing complaints. Obtain and examine all relevant information to assess validity of complaints and to determine possible causes. Abide by all obligations under HIPAA related to Protected Health Information (PHI). If a HIPAA violation is discovered, whether individually or by another, you must report the violation to the Compliance Officer and/or Human Resources. Attend, complete, and demonstrate competency in all required HIPAA Training offered by the company. Flexibility to understand, appreciate and embrace that this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee. Duties, responsibilities, and activities may change, or new ones may be assigned at any time with or without notice.

Requirements

Interacting with Computers
Communicating with Supervisors, Peers, or Subordinates
Getting Information
Communicating with Persons Outside Organization
Processing Information
Resolving Conflicts and Negotiating with Others
Updating and Using Relevant Knowledge
Organizing, Planning, and Prioritizing Work
Performing Administrative Activities
Making Decisions and Solving Problems
Customer and Client Focus.
Problem Solving and Analysis.
Time Management.
Communication Proficiency.
Teamwork Orientation.
Technical Capacity.
Multitasking
Competencies as a Certified Pharmacy Technician (CPhT).
High School or equivalent.
Customer service experience.
Certified Pharmacy Technician Certification (CPhT) with experience in a pharmacy setting.
Computer experience.

Responsibilities

Provide effective customer service for all internal and external customers.
Use excellent, in-depth knowledge of company products and programs.
Communicate effectively with team members within the clinical department.
Assist in clinical situations and resolutions.
Confer with customers by telephone to provide information about Rx claims processing.
Keep detailed records of customer interactions or transactions.
Follow-up to ensure that appropriate changes were made to resolve customers' problems.
Refer unresolved customer grievances to designated departments for further investigation.
Review Rx insurance policy terms to determine whether a claim is covered for employer group.
Contact customers to respond to inquiries or to notify them of claim investigation results or any planned adjustments.
Resolve customers' service or billing complaints.
Obtain and examine all relevant information to assess validity of complaints and to determine possible causes.
Abide by all obligations under HIPAA related to Protected Health Information (PHI).
Report HIPAA violations to the Compliance Officer and/or Human Resources.
Attend, complete, and demonstrate competency in all required HIPAA Training offered by the company.