This position serves as a first line resource for all callers regarding program eligibility, benefit structure, and service availability for members, patients and providers. This position is responsible for accurate and timely written and/or verbal response to member, patient and provider inquiries for all health care programs administered by the Health Care District. Once an inquiry is received, the position must review and verify the current member status or provider participation. This position must research, analyze and prioritize the member and/or patient, or provider concern and determine appropriate action based on issue presented. This position is responsible for knowledge of the most current benefit structure and network availability for each program administered by the Health Care District. This position is responsible for conveying pharmacy benefit and troubleshooting skills to the membership and network participants to ensure access to needed medications through plan benefits and outside patient assistance programs not maintained by the Health Care District. This position is responsible for claims research and analysis to determine appropriate follow-up when network. This position is responsible for being the initial contact point regarding all health care plans complaint and grievance process. This position is responsible for all C.L. Brumback Primary Care Clinic and Dental Clinic and lab services patient registration, scheduling, inquiries, complaints and compliments. This position is responsible for maintaining current knowledge and adherence of the current HIPAA guidelines.
Responsible for all calls directed through the call centers (from C.L. Brumback Clinics, Dental Clinics, Member, Provider and main line).
Documents, researches and responds to customer/patient/provider inquiries, complaints, concerns, or grievances in a concise and professional manner for the purpose of maintaining accuracy of the customer service database and to coordinate information with other departments.
Documents customer inquiries, complaints, concerns, or grievances Identifies complaints requiring additional review by senior personnel.
Research and advise both member and provider inquiries concerning the status of requested authorizations for health care services.
Research and respond to inquiries concerning medication prescribed for adherence to the appropriate Pharmacy Formulary in effect for the member’s health plan. Works with the Pharmacy Department and the Pharmacy Benefit Manager (“PBM”) acting as the member/patient advocate.
Maintain knowledge of and ability to advise members and providers of alternative programs for non covered services or medication.
Assists in processing department mail, researching cases, mailing information, and other department duties as directed.
Responsible for the registration of all patients for primary care services, dental services and lab services.
Knowledgeable on all accepted health plans and responsible for collecting accurate information for billing process. Ability to comprehend patient billing statement and advise member appropriately.
Research and advise provider representatives of claim status for payment or denial status
Research and advise provider representatives of appeal status for reprocess of claim or denial of appeal.
Research and respond to fax requests from provider network requesting claim status, eligibility status and appeal status within departmental timeframe of one (1) business day.
Provides answers to all questions related to program eligibility, status of pending eligibility, program benefits, Clinic operations, dental operations, lab operations, registration, scheduling, billing, claims status, request for review status, Authorization status.
Works directly with the Provider Services Department, Intake, Authorizations, Claims, Finance to provide resolution to all inquiries within a set time frame.
Responsible for data clean up within multiple operating systems. This includes (not limited to), member/patient name, DOB, demographics to ensure effective mailings and revenue cycle.
Responds to and assists anyone that present themselves to the Administrative Offices.
Acts as back up for Collaborative Agency enrollment activities including data input, data quality assurance, and application inventory control. Provides timely feedback to internal staff and external agencies regarding workflow processes.
Acts as back up for reassignment of members via a provider contract change.
Knowledgeable of all community resources and assists callers with participating with community resources available. This includes but not limited to; pharmacy assistance programs, community grant programs, pro bona programs or reduced payment programs.
Researches database for member duplication, updates records referencing duplication for claims processing.
Develops and maintains a positive working relationship with the members and patients for the purpose of maintaining enrollment and member retention.
Provides outreach to all new patients assigned to the C.L. Brumback Clinics and Dental Clinics. Provides outbound calls to welcome the patients and assist with scheduling a health risk assessment for primary care services as well as dental.
Assists with all member and patient surveys upon request to increase member and patient satisfaction.
Works on special projects and performs other duties as assigned.
Ability to communicate information in a clear, concise and timely manner while using appropriate verbal and written channels of communication.
Demonstrate problem solving skills and the ability to recognize opportunities for improvement and take appropriate action when necessary.
Maintain and update comprehensive knowledge of medical terminology and pharmacy terminology.
Ability to meet and/or exceed departmental ACD Call Center goals.
Emergency duty may be required of the incumbent that includes working in special needs or Red Cross shelters or to perform other emergency duties including, but not limited to, responses to threats or disasters, man-made or natural.
High school diploma or GED required. Associate’s degree in Business Administration, Marketing, or Health Services preferred.
Three (3) years progressively responsible experience in a customer service role in the health care industry or in a health insurance environment; or an equivalent combination of education, training, and experience required. Bilingual preferred (Spanish/English and/or Creole/English).
Valid Driver’s License required.