Customer Service Representative I - Fort Wayne, United States - Physicians Health Plan Of Northern Indiana, Inc

Description

Position Purpose:
This position responds to all incoming calls and member walk-ins. Provides information as requested relating to enrollment, review of status, and claims. Identifies questions related to contract interpretation and claims processing.

Researches payment of claims, coordination of benefit problems, enrollment issues, pharmacy issues, COBRA questions and, as needed, employer group or provider problems/issues.

In conjunction with Case Management, coordinates and investigates off-plan referrals, and works to resolve all third party vendor issues. May work in multiple product lines (HMO, Level Solutions, or consumer driven plans).


Primary Responsibilities:

• To perform this job successfully, the individual must be able to perform each essential duty in accordance with the Customer Service Departmental standards (the requirements listed below are representative of the knowledge, skill and/or ability needed).

Reliable, consistent and predictable performance of the following job duties is required:
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• Provides information to multiple client bases concerning benefits and coverage, as well as claims status.
• Provides information and support for claims adjustment processes.
• Verifies member eligibility and benefits to all appropriate callers.
• Supports member ID card production, including mailing, corrections, returned mail, etc.
• Tracks and trends provider issues for coordination with Provider Network Services Department.
• Maintains current product, medical policy, contract information, and other reference materials.
• Investigates and may take new member COB information over the phone.
• May contact new enrollees to welcome them to the Plan.
• May perform duties such as testing system upgrades, auditing contracts, auditing explanation of benefits, revisions and updates, receptionist coverage, assisting with mailings for other areas, training Claims backups, learning newly developed products, and attending seminars and classes.
• Utilizes extensive department reference tools effectively, such as Encoder Pro, scanning/records retention programs, policies, procedures and guidelines to accurately answer all questions.
• Maintains departmental standards relative to accuracy, assuring compliance with federal and state laws.
• Researches and utilizes precertification information.
• Assists Customer Service Supervisor with the development and maintenance of departmental policies, procedures and workflows.
• Monitors weekly pend report for followup and resolution.
• Handles incoming mail as distributed in accordance to departmental alpha split.
• Monitors services levels in phone ques.

Critical Required Skills:

• Excellent verbal, listening, written and interpersonal skills.
• Excellent problem solving, negotiation, and diplomatic skills.
• Excellent technical skills, primarily using telephone and computer systems.
• Highly developed analytical and organizational skills required to manage large amounts of information, diverse questions and problems.
• Extensive knowledge of products and benefits, medical policy, contracts and contracting, COB, and other businessrelated information.
• Ability to selfmanage, prioritize efforts, meet specific deadlines, solve problems, and troubleshoot multiple issues concurrently.
• A high level of computer literacy to support information management relating to all facets of customer service.
• Effective indepth research skills.
• Must be able to work well independently and in a team atmosphere.
• Detailed oriented.

Key Challenges:

• Effectively answering incoming customer service calls, dealing with complaints, questions and concerns effectively, and building an understanding of the customer's situation/issues.
• Explaining contract provisions and benefit coverage in terms understandable to members.
• Researching simple and complex customer problems and identifying effective solutions.
• Efficiently managing large amounts of information while maintaining an effective uptodate information management system to support those efforts.
• Strong verbal, written and interpersonal communication skills.
• Effectively negotiating with clients, providers, and members to resolve any type of problem.
• Ability to selfmanage efforts, and coordinate with other Customer Service Representatives, Enrollment employees, and other PHP personnel in providing exceptional customer service to our constituents.
• Working sensitively and effectively in a stressful, problemsolving environment, with a large diversity of problems and individuals, primarily using the telephone.
• Coordinating member issues with Case Managers and/or Utilization Review Nurses, including tracking of retroadjustment authorizations, claims adjustments, and administrative hold issues.
• Coordination of all COB implications relating to new clients and members.
• Maintaining an uptodate resource base regarding product, medical policy, contract information and other reference materials as need