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Provides outreach to members and conducts initial calls for potential member/patient screening. Provides customer service by receiving incoming calls from members, providers and others. Coordinates member requirements with providers, clinical coordinators, case managers, other departments or organizations as appropriate. Assists other callers as necessary. Complies with organizational policies and procedures, regulatory requirements and other established criteria and guidelines. Maintains confidentiality of business and protected health information. Performs data entry, administrative support, reporting and other related functions as required.
DEPARTMENT: Operations/Customer Service
REPORTS TO: Supervisor, Customer Service
- Conducts outbound calls to members as appropriate for the needs of the department, LOB, and markets.
- Collects and verifies information concerning eligibility, provider status, benefit coverage, coordination of benefits and subrogation.
- Provides customer service functions and coordinates member needs with the appropriate level of care.
- Applies policies and procedures, regulatory requirements and accreditation standards to all activities.
- Performs data entry of authorizations, contacts, in the EMMA system and schedules nursing assessments in Outlook.
- Special projects including fulfillment of educational material, data entry, research, records retrieval, etc.
- Receives and sends incoming and outgoing faxes.
- Receives and distributes incoming and outgoing mail.
- Assists in preparing and submitting projects, reports or assignments as needed to meet organizational initiatives and/or objectives.
- Performs other duties as assigned.
- Required a High School or GED
- Preferred an Associate's Degree in social work, nursing, rehabilitation, special education, health education or a related human services field or directly related
- Required 2 years of experience in member services, provider services, call center or customer services within a managed care organization or call center environment and/or transferable member outreach and telephonic engagement experience/skills
- Preferred 1 year of experience in a health organization, medical office or medical facility with telephonic member engagement that serves adults and children with serious illness
- Intermediate knowledge of healthcare delivery
- Intermediate knowledge of community, state and federal laws and resources
- Intermediate demonstrated interpersonal/verbal communication skills
- Intermediate demonstrated organizational skills
- Intermediate demonstrated written communication skills
- Intermediate demonstrated time management and priority setting skills
- Intermediate ability to effectively present information and respond to questions from families, members, and providers
- Intermediate ability to calculate basic math.
- Required beginner Microsoft Excel
- Required beginner Microsoft Word
- Required beginner Microsoft Outlook
- Preferred bilingual helpful