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    Enrollee Services Representative - Maryland Line, United States - Ageatia Global Solutions

    Ageatia Global Solutions
    Ageatia Global Solutions Maryland Line, United States

    3 weeks ago

    Default job background
    Description
    PRINCIPAL ACCOUNTABILITIES:
    Enrollee Service Representatives serve as Enrollee and Provider advocates who provides guidance, assistance and education to Enrollees, caregivers, and providers answering basic question regarding Enrollee health care needs, benefits and effectively resolve issues raised by Enrollees primarily through inbound calls.
    Under the direct supervision of the Manager of Enrollee Services, the Enrollee Services Representative is responsible to:
    • Provide adequate customer service to our enrollees, vendors and providers
    • Identify callers concerns and provide resolution for the inquiry
    • Assist enrollees with a request to change or select a PCP (Primary Care Provider)
    • Re-issue enrollee ID cards as requested
    • Assist enrollees with questions related to their benefit plan
    • Obtain and update demographic information
    • Assist Enrollees face to face who walk-in the office
    • Assist irate callers to resolve their issue
    • Assist Enrollees with filing a grievance and forwarding to the appropriate department
    • Document all interactions with callers
    • Interact with pharmacies when appropriate
    • Identify trends with enrollees and providers that can affect daily operations
    • Process return mail, enrollee cards and packets
    • Facilitate special transportation request
    • Provide clarity to providers on basic claim questions
    • Educate providers on internal processes for claims, authorization, and appeal/grievance submission
    • Confirm the status of a claim (paid/denied)
    • Direct providers to appropriate internal departments for further assistance
    • Confirm eligibility and PCP assignments to providers and contracted vendors
    • Follow company and department policies and procedures
    • Meet department call center goals for abandonment rate, service level and speed of answer
    • Participate in community events
    • Other duties as assigned
    Required Experience/Skills/Abilities:
    • Minimum two (2) years of call center experience
    • Experience with health care benefits or DC Medicaid, Managed Care experience preferred
    • MHC preferred
    • Experience with Facility and Professional audits of claims
    • Knowledge of ICD-10 and HCPC codes, Client, Emdeon and eligibility tools
    • Proficient in Microsoft Office tools (Excel, PowerPoint)
    • High level understanding of the claims process.
    • High School Diploma or GED
    • Call Center experience, Medical Insurance background (a plus but not required), Bilingual (a plus but not required)
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