The Customer Service Representative is the face of Seaside and impacts members' service experience by how customer service inquiries and problems via telephone, internet or written correspondence are handled. The CSR maintains a positive caller experience at all times.
Essential Functions and Responsibilities:
Documents and tracks contacts with members, providers and plan sponsors; triages rework to appropriate staff.
Guides the member through their member's plan of benefits, Seaside policy and procedures as well as having knowledge of resources to comply with any regulatory guidelines.
Creates an emotional connection with our members by understanding and engaging the member to the fullest to champion for our members' best health.
Takes accountability to fully understand the member's needs by building a trusting and caring relationship with the member.
Anticipates customer needs. Provides the customer with related information to answer the unasked questions, (e.g. additional plan details, benefit plan details, member self-service tools, etc.)
Explains member's rights and responsibilities in accordance with the contract and regulatory requirements. Processes claim referrals, new claim handoffs, nurse reviews, complaints (member/provider), grievance and appeals (member/provider).
Educates providers on our self-service options
Responds to Subpoena requests for medical records and other information.
Assists in the preparation of complaint trend report.
Handles incoming requests for appeals and pre-authorizations not handled by Medical Management.
Performs review of member claim history to ensure accurate tracking of benefit maximums and/or coinsurance/deductible.
Uses applicable system tools and resources to produce quality letters and spreadsheets in response to inquiries received.
Be at work and be on time.
Follow company policies, procedures and directives.
Interact in a positive and constructive manner.
Prioritize and multitask.
High School diploma or GED equivalent, required
Bachelor’s Degree, preferred
Minimum of two years experiences in a transaction-based environment such as a call center or similar environment.
Experience in a managed healthcare environment, preferred.
Excellent communications skills including the ability to write and articulate in a clear, concise and persuasive manner to effectively present ideas with ease.
Demonstrated ability to be empathetic and compassionate.
Basic computer skills, including general knowledge of MS Word and Excel applications, type minimum of 45 WPM.
Bi-lingual (Spanish/English) preferred
Internal Number: SEA000086
About Seaside Health Plan
Let us introduce ourselves. We're MemorialCare, a nonprofit health system that includes four hospitals, two medical groups, imaging centers, surgical centers and much more. As one of the leading health systems in Orange County and Los Angeles County, we're confident that no matter what your needs are, we have the teams, tools and know-how to support you every step of the way.