Customer Advocate (Medical Claim Processor & CSR)

Job Title: Customer Advocate (Customer Service Rep & Claims Processor)

Summary/Objective: Responsible for providing customer support to members and providers regarding their plan documents, benefits and claims, processing explanations and provider network. Responsibilities also include accurate and timely claims adjudication, documentation of all customer interactions and other administrative or office duties as assigned.

Supervision Received: Claims Manager/Supervisor

Essential Functions:

ADMINISTRATIVE FUNCTIONS

1. Respond to and resolve customer inquiries via telephone, email or other correspondence regarding plan benefits, claims status and eligibility.

2. Answer incoming telephone calls and written requests for information from customers promptly and accurately.

3. Have a solid working knowledge of all company product and service offerings and can communicate all offerings effectively and concisely.

4. Document member/provider/client contacts accurately including all relevant details and follow up requirements in customer service call tracking software.

5. Work collaboratively with other employees to ensure timely and appropriate responses to all customer inquiries, no matter how complex they may be.

6. Data Entry and adjudication of medical claims and treatment requests into transaction system maintaining productivity, accuracy, and follow-up standards identified by supervisor.

7. Acts as a role model in demonstrating the core values in customer service delivery.

8. Provides timely and thorough follow up with, internal and external customers.

9. Appropriately escalates difficult issues up the chain of command.

10. Serves on committees, work groups, and/or process improvement teams, as assigned, to assist in improving quality/customer satisfaction.

11. Recognizes and alerts appropriate supervisor of trends within their scope of responsibility that fall outside of quality parameters.

12. Performs self quality monitoring to develop and execute plans to meet established goals.

13. Provides ongoing feedback to help optimize quality performance.

14. Collaborates with others and cross-departmentally to improve or streamline procedures.

15. Develops new or improves current internal processes to improve quality

MANAGEMENT FUNCTIONS

None

BUSINESS FUNCTIONS

1. Compassionate Nature with an ability to have empathy and look for solutions that are customer focused within the compliance guidelines of the organization.

2. Strong communication skills; listening and speaking/writing.

3. Strong computer skills – ability to use all standard office programs.

4. Proven ability to meet performance standards and goals.

5. Ability to work independently in a fast-paced environment as well as contribute to the overall team and company mission and goal while maintaining accuracy and production requirements.

6. Excellent time management and organizational skills.

Required Education/Experience: High School Diploma or Equivalent with a preferred experience in healthcare related Customer Service/Call Center and/or Claims Examiner.

Additional Eligibility Qualifications

Possess personal qualities of integrity, credibility, and commitment to corporate mission.

Flexible and able to multitask; can work within an ambiguous, fast-moving environment, while also driving toward clarity and solutions.

Environmental/Work Conditions: This job operates in a professional office environment. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines. Current hours are Monday through Friday from 8:00am - 5:00pm. Hours for customer service may change going forward and will be communicated by management should that be the case.

Physical Demands: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to talk and hear. The employee frequently is required to stand; walk; and reach with hands and arms.

Job Type: Full-time

Pay: From $21.00 per hour

Benefits:

• 401(k) matching
• Dental insurance
• Health insurance
• Paid time off
• Parental leave
• Vision insurance

Ability to Relocate:

• Fresno, CA 93720: Relocate before starting work (Required)

Work Location: In person