Customer Service Representative

This position will be responsible for making daily member telephone calls, which will include directing members to the proper services they need, educating them, problem-solving, and creating linkages to the Medical Management Department for authorization of services. Also may be responsible for assisting providers with eligibility, benefit, and resolution of claims issues.

Essential Functions and Responsibilities:

1. Meets the Department standard of calls answered and call documentation entered.
2. Assists Members and Providers with questions and concerns.

• Finding Provider(s)/Services for members
• Arrange Transportation for members
• Answer billing/claims status questions; resolve claim issues for members
• Assist with pharmacy issues
• Help Members access community support services
• Verify member eligibility
• Quote benefits
• Assist with Referrals
• Assist with member health assessments
• Assist members with closing gaps in care

1. Ongoing member education.
2. Responsible for all benefits information given to Members and Providers.
3. Participates in Departmental Projects, as appropriate.
4. Coordinates quality improvement initiatives with Medical Management, Provider Relations, and Quality Depts., i.e., Preventative Health Screenings.
5. Other duties as assigned or when necessary to maintain efficient operations of the department and the Company as a whole.