Customer Service Representative I

Santa Clara Family Health Plan•San Jose, CA

13d

About The Position

The Customer Service Representative I answers inbound calls and makes outbound calls to support Customer Service Department operations in a manner that maintains compliance with Medicare and Medi-Cal regulatory requirements and achieves Call Center service-level objectives.

Requirements

High School Diploma or GED. (R)
Minimum one year of experience in Customer Service or Call Center role, preferably within a Health Care, Public Assistance or Human Services programs. (R)
Ability to meet Key Performance Indicators by participating in and achieving the standards of the Customer Service Call Center Quality Program. (R)
Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications, such as Outlook, Word and Excel. (R)
Ability to use a keyboard with moderate speed and a high level of accuracy. (R)
Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP Plan members and providers over the telephone, in person or in writing. (R)
Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R)
Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R)
Ability to maintain confidentiality. (R)
Ability to comply with all SCFHP policies and procedures. (R)
Ability to perform the job safely with respect to others, to property, and to individual safety. (R)

Nice To Haves

Prior experience with managed care plans, Medi-Cal and Medicare programs, and working with underserved populations. (D)
Spanish, Vietnamese, Chinese, or Tagalog language bi-lingual skills. (D)

Responsibilities

Act as the primary point of contact and liaison for SCFHP members and providers contacting the plan regarding general inquiries, concerns or requests for information.
Develop a general understanding of all member facing materials, communications and interactions and be prepared to respond appropriately to follow up calls.
Answer inbound calls and/or place outbound calls in a high call volume environment and work directly with members and providers to accurately and completely answer inquiries involving SCFHP program services and benefits.
Follow established guidelines and resources to respond to member and provider inquiries and resolve concerns in an accurate, timely, professional, and culturally competent manner.
Intake, handle and coordinate member grievances, appeals and billing issues, escalating to the Grievance and Appeals department, when necessary.
Educate members and providers on eligibility, and medical and pharmacy benefits and how to access services in a manner that achieves excellent service standards and maintains high customer satisfaction.
Use listening skills and judgment to appropriately categorize and accurately document all contacts and follow-up actions regarding member and provider communications and activities in accordance with established guidelines.
Appropriately handle member and provider requests through alternative channels such as e-mail, voicemail, fax, walk-in, etc. in accordance with established procedures.
Triage member and provider requests or inquiries for other departments.
Conduct member surveys as assigned in accordance with established guidelines.
Attend and actively participate in daily, weekly, and monthly departmental meetings, in-services, training and coaching sessions.
Identify member/provider issues and trends and report relevant information to management.
Perform other related duties as required or assigned.