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Our Customer Service teams have a serious responsibility to make every contact informative, productive, positive, and memorable for what it says about how much we care.
Employees in this position include those responsible for initial Triage of members, Administrative Intake of members or managing the Admission/discharge information post-notification, and working with hospitals and the Clinical team. Function includes managing Incoming calls, managing requests for services from Providers/members, providing information on available Network services and transferring members as appropriate to Clinical staff. Also manages the Referrals process, processes Incoming and Outgoing Referrals, and Prior Authorizations. This function also includes Intake, Notification and Census roles.
- Respond to Incoming Provider and Enrollee calls
- Resolve Customer Service inquiries
- Provide excellent Customer Service to both Providers and Enrollees.
- Constantly meet established productivity, schedule adherence, and quality standards while maintaining good attendance.
- Receives Care Coordination notification cases for non-clinical assessment/intervention and provides appropriate triage
- Processes out of network requests for consideration of in network level of benefits for physician specialty referrals for appropriate products
- Processes notification requirements for outpatient procedures, home health, DME, transition of care, and network gap issues
- Determines benefit coverage issues based on employer group contracts
- Sets up/documents/triages cases for (CCR) Clinical Coverage Review
- Ensures all potential member needs are identified and forwarded to the appropriate Care Coordinator for risk validation when applicable
- Processes letters within DOL time frames
- Verifies appropriate ICD-10 and CPT coding usage
- Communicates to providers and members benefit determinations within DOL time frames
- Assist with faxes and emails
- Moderate work experience within own function
- Some work is completed without established procedures
- Basic tasks are completed without review by others
- Supervision/guidance is required for higher-level tasks
- Other duties as assigned by manager and/or director