Customer Service Representative I - Health Assistance

Job Description

Position Purpose and Description

A customer service representative is responsible for assisting members and medical providers over the telephone and via email by providing information on members’ health plans.

He / she will be required to validate the member’s policy, provide policy benefits and confirm a member’s eligibility. He / she will also be required to respond to inquiries regarding the status of authorizations and bills as well as assist members in locating appropriate medical providers.

A customer service representative is expected to promote service excellence in all communications with members, providers and corporate clients.

A level one customer service representative is defined as being fully trained on all products and services provided by the Health Assistance Team, as indicated below.

During off-hours, in addition to the above, he / she will be responsible for responding to requests from corporate clients which can include;

sending eligibility and benefit details to medical providers, providing bill status, arranging medical appointments and other services.

Expected Outcomes & Actions

1. Case and Call management :

• a. Provide benefit and eligibility information on several insurance products to members and providers including the conditions and exclusions for each product;
• b. Advise providers and members of services requiring prior authorization and the process to obtain authorization;
• c. Obtain all necessary information to request authorization and open a claim following the appropriate guidelines;
• d. Document all communications in the claims management system;
• e. Provide members with referrals to in network providers; confirm providers network participation and validate billing details;
• f. Respond to member inquiries on claim status including process date, payment amount, payment details, etc.;
• g. Monitor team mailbox and respond to member, provider and client communication and follow up accordingly;

h. Coordinate medical appointments for members by liaising with the member and the appropriate medical provider

2. Administrative support :

a. Complete administrative tasks as delegated by the team leader and according to business needs, including, but not limited to triage, Go-Trex tasks, etc.

3. Off-hours additional tasks :

• a. Respond to requests received from Corporate Clients during off-hours, subsequently adding the information to the claims system, following up on the clients’ requests, and sending confirmations and updates to the Corporate Client;
• b. Monitoring urgent Case Management claims; taking the appropriate action and following up on authorizations; contacting Corporate Clients to request necessary information for Case Management claims;

Major Job Accountabilities

• Customer Experience providing excellent customer service as per customer experience guidelines;
• Quality opening quality claims according to claim opening guidelines;
• Efficiency managing workload as per productivity guidelines i.e. average CHT, EHT, Task turnaround times, etc.;
• Adherence and Absenteeism adhering to the work schedule.

KSA (Knowledge, Skills and Abilities / Attitudes)

• Superior customer service skills;
• Excellent interpersonal skills;
• High level of professionalism;
• Good problem-solving skills;
• Highly organized with ability to multi task and prioritize;
• Ability to handle stress

Requirements and Qualifications

• High School Diploma or equivalent;
• One to two years of experience in a customer service-related position;
• Clear and effective communication (written and verbal) in English plus French and / or Spanish and / or German.
• Proficiency in the Microsoft suite products.

We offer you

Global Excel offers more than a position; we offer a professional future with a competitive compensation including base salary, performance bonus and benefits.

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