Primary Job Purpose
Open to all applicants within: Oregon, Washington, Idaho and Utah
The Customer Service Professional I role is a full-time remote position
Position starts: Monday, June 14th
Position closes to new applicants: Thursday, May 20th
The Customer Service Professional I provides information, education and assistance to members, providers, other insurance companies, attorneys, agents/brokers or other customer representatives on recorded phone lines regarding benefits, claims and eligibility. They also provide excellent and caring services to all internal and external members and providers.
The Customer Service Professional I is likely to be the primary contact between the corporation and members and providers. The manner in which a member or provider is treated during that contact is critical to retaining our customers and to the overall success of the corporation.
General Functions and Outcomes
Successfully complete training period and meet dependability, timeliness, accuracy, quantity, and quality standards as established by department. Study, review and learn information, procedures and techniques for responding to a variety of inquiries.
Communicate with a variety of subscribers, providers, healthcare providers, agents/brokers, attorneys, group administrators, other member representatives, internal staff and the general public with inquiries regarding benefits, claim payments and denials, eligibility, decisions, and other information through a variety of media - oral, written and on-line communications. Respond to multiple inquiries on all designated lines of business.
Quickly and accurately assess provider and member inquiries and requirements by establishing a rapport inquirer in order to understand his/her service needs. Identify errors promptly and determine what corrective steps may be taken to resolve errors.
Apply benefits according to appropriate contract. Determine benefit payments, maximum allowable fees, co-pays, and deductibles from appropriate contracts.
Make appropriate corrections of denied, process-in-error or re-classified claims.
Explain benefits, rules of eligibility and claims payment procedures, pre-authorizations, medical review and referrals, and grievance/appeal procedures to members and providers to ensure that benefits, policies and procedures are understood.
Educate members and providers on confusing terminology and policies such as eligible medical expenses, hold harmless, medical necessity, contract exclusions and limitations, and managed care products.
Maintain confidentiality and sensitivity in all aspects of internal and external contacts.
Manage high volume of calls on a daily basis, prioritize follow-through and document member and provider inquiries and actions on tracking system and/or by completing logs. May generate written correspondence and process document requests.
Maintain files/records of constantly changing information regarding benefits/internal processes including company-wide internal policies and benefit updates for new or existing business. Work is subject to audit/checks and requires considerable accuracy, attention to detail and follow-through.
Comply with NMIS/MTM and Consortium standards as they relate to the employee's responsibility to meet BlueCross BlueShield Association (BCBSA) standards and corporate goals.
Assist in identifying issues and trends to improve overall customer service.
For HMO related work: Enter, correct and adjust referrals according to established policies and procedures. Explain referral rules, processes to providers and internal customers.
Keyboarding skills of 30 wpm with 95% accuracy.
Proficient PC skills and prior experience in a PC environment.
Demonstrated knowledge of medical terminology and coding preferred.
Ability to apply mathematical concepts and calculations.
Ability to communicate effectively orally and in writing with understanding and ability to apply correct punctuation, spelling, grammar and proof-reading skills.
Demonstrated ability of strong customer-service skills, including courteous telephone etiquette.
Ability to make decisions and exercise good judgment in a complex and rapidly changing environment.
Ability to adapt to a fast-paced environment and learn, retain, and interpret new or evolving information, procedures, and policies and communicate them effectively.
Ability to work under stress and pressure and respond to inquiries with tact, diplomacy and patience.
Ability to work in a team environment.
Ability to exercise discretion on sensitive and confidential matters.
Demonstrate initiative in researching and resolving benefit, and eligibility issues.
Our call centers are open 5am-8pm (PST) M-F and 8am to 4:30 pm (PST) on Saturdays. You may be asked to work a schedule on Saturdays or until 8pm during the week.
This is a full-time and permanent remote position
Pay will be discussed when recruiter reaches out
Normally to be proficient in the competencies listed above
Customer Service Professional I would have a high school diploma or equivalent and 6 months of customer service call center experience or 6 months of customer service experience such as insurance, retail, banking, restaurant, hospital medical office or other experience with extensive customer service contact or equivalent combination or education and experience.
This is a permanent remote position
May be required to work overtime.
May be required to work outside normal hours.
We are an Equal Opportunity and Affirmative Action employer dedicated to workforce diversity and a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A drug screen and background check are required.
If you need accommodation for any part of the application process because of a medical condition or disability, please email . Information about how Cambia Health Solutions collects, uses, and discloses information is available in our .