Senior Customer Service Representative

Opportunity to join our health plan Enrollment team. Assists in resolving customer concerns, providing appropriate education/instruction and maintaining customer satisfaction by providing the highest level of customer service in only one of the Primary Functions (enrollment, claims or phones). Actively participates in cross training, improving processes within the Customer Service team.

Job Duties

• Resolves and reconciles enrollment reports and all related eligibility issues by following policy and procedure as well as any state legislated coverage and eligibility guidelines.
• Initiates communication and literature to the newly enrolled Health Plan member, dependents and employer groups.
• Interprets and appropriately applies rules and regulations in contractual agreements and with employer groups and vendors.
• Performs membership data extract reports and supplies them to employer groups as an audit tool for accuracy and compliance with performance risk guarantee commitments.
• Updates, approves and interprets membership data and workflow produced by online software capabilities in employer group modules.
• Determines the eligibility of most members as well as processing terminations and disenrollments.
• Prepares, generates and appropriately disseminates letter communications to subscribers and members with regard to enrollment activity.
• Determines if services received are covered benefits as applicable by line of business and product design.
• Reviews suspended claims for resolution by applying current policies, procedures and benefits applicable to specific products.
• Provides team building resources to assist in directing peers to proper claims resolution policies and procedures in order to assist members and providers.
• Provides daily support and advice to member and provider services staff regarding claims issues.
• Researches claim issues from participating providers and identifies specific criteria for reconsideration for payment.

Work is typically performed in an office environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.

Position Details

Internet requirements:

Employee required to have/supply: Cable modem, (high speed, only - No DSL or Wireless Cellular Service or Satellite Service) The minimum requirement is:

• • 5 MBPS UP
  • 20 Mbps DOWN
  • <75 ms Ping Required
  • <30ms Gitter Required

• Computer must be connected to the internet via Ethernet cable; wifi is not permitted unless a Virtual Private Network (VPN) is used for the wifi connection

Education

High School Diploma or Equivalent (GED)- (Required)

Experience

Minimum of 1 year-Customer Service (Required)