Essential Functions:
Responsible for inbound phone inquiries, primarily dealing with either:
Member benefits and eligibility related to the HMO, EPO/PPO, Medicare and Medicaid, CHP and FHP product lines or
Provider benefits, eligibility, PEP and claim status, member pharmacy calls, utilizing prior approval skills (ACP/DME and CCD) and placing outbound calls on a routine basis.
Resolve issues with respect to benefits and eligibility by researching documentation, system information or gaining knowledge from other employees, management or departments.
Interact with customers, document call specifics and demonstrate quality program behaviors to create an outstanding relationship with each caller.
Work with outside vendors as needed to answer questions or resolve issues.
Respond to member correspondence/email in writing utilizing an existing CSS system letter to effectively respond to members.
Conduct orientation to new members by providing an overview of the member’s plan and pertaining administrative policy.
Skills, Experience and Education requirement:
Excellent oral communication skills in English
High School Diploma
Experience with member and provider calls in Healthcare Insurance
Understanding of Medicaid and PCP. Overall knowledge of Medical Claims, Authorizations and Referrals
Domain Skills
| SNo | Primary Skill | Proficiency Level * | Rqrd./Dsrd. |
| 1 | Claims | NA | Desired |
| 2 | Medicare & Medicaid Claims | NA | Desired |
* Proficiency Legends
| Proficiency Level | Generic Reference |
| PL1 | The associate has basic awareness and comprehension of the skill and is in the process of acquiring this skill through various channels. |
| PL2 | The associate possesses working knowledge of the skill, and can actively and independently apply this skill in engagements and projects. |
| PL3 | The associate has comprehensive, in-depth and specialized knowledge of the skill. She / he has extensively demonstrated successful application of the skill in engagements or projects. |
| PL4 | The associate can function as a subject matter expert for this skill. The associate is capable of analyzing, evaluating and synthesizing solutions using the skill. |
Source: Monster.com
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