POSTED: January 3, 2025
POSITION: Customer Service Representative
DEPARTMENT: Operations/Customer Service
BASE RATE: $17.09 per hour, with potential for additional compensation based on qualifications.
POSITION SUMMARY:
Provides customer service for members and providers in a positive and professional manner. Effectively interacts with the operations team, other internal departments, and business partners. Engages in inbound and outbound calls, routes information to appropriate persons/departments, and resolves member issues. Ensures comprehensive and accurate data is entered into applications as required.
ESSENTIAL DUTIES AND RESPONSIBILITIES:
Follows all established UPHP policies and procedures, objectives, safety standards, and sensitivity to confidential information.
Meets established production and call performance metrics and ensures a positive customer service experience for members and providers. Documents all member and provider correspondence in the claims management database.
Assists members of all UPHP product lines with questions about benefits, policies, eligibility, medication denials, participating providers, and accessing care.
Assists members of all UPHP product lines in filing and/or resolving complaints, grievances, and appeals.
Assists providers with eligibility and benefit questions and any member medication issues and routes information as appropriate; provides information related to grievances/appeals.
Assists pharmacy providers with eligibility questions and provides information on pharmacy benefits, medication denials, medication appeals, and routes information to the pharmacy department as necessary.
Stays informed on UPHP, Medicaid and Medicare policies and processes impacting UPHP lines of business and beneficiaries, as well as pharmacy formulary updates and website changes.
Works closely with clinical services, claims, and transportation regarding authorizations, referrals, pre-notifications, benefit exceptions, and projects that benefit the organization.
Processes incoming release of protected health information documentation.
Facilitates routine and ad-hoc member outreach as directed by the customer service supervisor or manager.
Acts as back up to the Receptionist as needed.
Supports National Committee for Quality Assurance (NCQA) Health Plan accreditation standards.
Maintains confidentiality of client data.
Performs other related duties as assigned.
POSITION QUALIFICATIONS:
Education:
Minimum:
High School Diploma or GED
• Preferred:
Associate in business administration, healthcare administration, or related field
Experience:
Minimum:
Two (2) years of general customer service or call center experience
Preferred:
Two (2) to three (3) years of customer service experience in healthcare, health insurance, or
related; experience in call documentation and data entry into Customer Relationship
Management (CRM) systems or similar platforms; experience with healthcare management
software is highly preferred.
Required Skills:
Keyboarding proficiency
Strong interpersonal and team collaboration skills
Working knowledge of MS Office (Word, Excel, and PowerPoint)
Digital dexterity
Exceptional customer service skills, problem-solving skills, and telep
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