Customer Service Rep I

Regal Medical Group•Los Angeles, CA

3d•Onsite

About The Position

Member Service Representative will play a crucial role in providing exceptional customer service to our members, addressing their inquiries, and ensuring they receive the support they need. Respond to telephone and occasionally in person inquiries from Members, Health Plans, Providers and Employer groups in providing information and clarification relating to RMG/LMG/ADOC services such as claims, referrals and eligibility and general information.

Requirements

High School diploma or equivalent is required.
Minimum 2 year customer service experience in a medical group or health plan setting is required.
Ability to deal responsibly with matters of a confidential nature.
Ability to prioritize work in order to meet daily deadlines.
Must have excellent communication skills, both verbal and written.
Ability to read, write and understand English and [Second Language].
Pleasant telephone manner.
Knowledge of HMO, DHS, DMHC and CMS regulatory guidelines.
Knowledge of CPT-4, HCPCS, Hospital Revenue and ICD-9 coding.
Knowledge of HMO, DHS, DMHC and CMS claims processing guidelines.
Strong knowledge of Microsoft Windows environment such as Word and Excel.
Self-starter, willing to take on multiple tasks.
Must be able to review and interpret health plan benefits and provider contracts.
Able to interface with customers both internal and external of RMG.
Ability to communicate effectively orally and written, typing 35 wpm.
Strong organizational skills with emphasis on prioritizing and attention to detail.

Responsibilities

Serve as the primary point of contact for members, addressing inquiries related to authorizations, billing, eligibility and general information.
This position is accountable for providing quality customer service handling incoming/ outgoing calls involving issues from members, providers and health plans.
Maintain or exceed quality and productivity standards of 35 calls per day with clear and concise detailed documentation of 90% incidents
Research and resolve routine or complex issues relating to services provided by RMG/LMG/ADOC. This includes eligibility, referral status, provider availability, case management, utilization management, billing related issues and general information.
Ability to work independently in the resolution of member complaints and other service related issues.
Resolve issues and concerns efficiently by coordinating with relevant departments and maintaining accurate records of member interactions.
Educate members on their rights and responsibilities, as well as the proper use of health care
Maintain up-to-date knowledge of HMO policies, procedures, and health care regulations to provide accurate information.
Facilitate communication between members and healthcare providers to ensure clarity and understanding.
Participate in training sessions and team meetings to enhance service delivery and share best practices.
Contribute to a positive and supportive team environment.
Prioritize assignments and other work functions in order to maintain workflow.
Display professionalism, good judgment, maturity, and fairness when interacting with others.
Perform copy and fax functions as needed.
Maintain accurate and good grammatical communication, both verbal and written, with all levels of management, staff, members and providers.
Follow HIPAA guidelines with all information pertaining to member medical information and privacy.
Display warm and pleasant phone personality, emphasizing tact, empathy and patience.
Other duties as assigned.