Provides customer service for health plan members, providers and group representatives via telephone on the products, benefits and provider networks, determining the company liabilities and obligations in varied medical circumstances. Resolves simple to complex inquiries from internal and external customers, deescalating emotionally charged callers. Uses technology and problem-solving skills and ensures compliance with department and regulatory requirements.
Job Responsibilities and Requirements:
Educates and informs members of available benefits under the health plan and coordinates the exchange of information among members, providers, and internal departments involved.
Instructs members how to receive maximum benefit reimbursement, including the advantages of utilizing their primary care physician and network providers.
Determines various policy provisions, guidelines, providers, and provider requirements and procedures; medical review procedures; and the procedures of company departments that apply to the need of the member.
Accesses and researches various information databases to provide answers and make appropriate decisions about the caller's situation.
Documents each phone call in accordance with department's standards, monitors the types of inquires received, and reports trends and concerns to management.
Stays abreast of related regulatory, compliance, and departmental updates to meet departmental metric requirements.
Performs other duties as assigned.
High school diploma or equivalent
No experience required
Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs.
Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements.
Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors.
Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc.
Frequent keyboard use/data entry.
Occasional bending, stooping, kneeling, squatting, twisting and gripping.
Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs.
Day Shift (United States of America)
Scheduled Weekly Hours:
SSM Health complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability or sex.