The primary role of a Customer Care Associate II is to provide excellent customer service to all Umpqua Health Alliance (UHA) members, providers and affiliates. To act as the hub of communication for our members by telephone and/or mail correspondence and serve as a dedicated resource to assist providers with claims inquiries. Provides additional support to the department by training new employees and mentoring them through the onboarding process. Assist the department management with resolving difficult cases and policy improvements..
ESSENTIAL JOB RESPONSIBILITIES
Work efficiently in a high volume call center while maintaining a professional, polite manner. Primary job function is to answer telephone inquiries, but additional duties include assisting walk-in customers, sorting and responding to inquiries received by mail/email in a timely manner.
Assist members or providers with questions related to benefit coverage, provider assignments, claims processing, and complaints.
Listen to member inquiries to determine steps for appropriate research and follow up for prompt resolution. Connect them to appropriate resources and coordinate resolution for issues and concerns.
Researches and responds to detailed provider inquiry issues received by email or via the phone queues.
Research and resolve provider data issues in relation to member assignment or claims processing to support the ongoing maintenance and health plan data integrity. Collaborating when needed with Provider Relations, Contracting, and/or Credentialing.
Document all calls in a clear and concise manner; route calls to the appropriate department/person as necessary.
Understand benefit plan coverage, enrollment, claims processing and policies accurately and be able to concisely communicate this information as necessary.
Process outgoing/incoming member mailings (ID Cards, Handbooks, etc.) on a regular basis, taking the appropriate actions to ensure members receive notifications timely.
Create and distribute plan materials in accordance with current workflow processes.
Handle member assignment and reassignment for primary and dental care providers on an ongoing basis following pre-determined criteria and timelines.
Conduct new member orientations, group training sessions for staff, and make presentations as needed.
Analyze customers inquiries and determine steps for resolution, interpret benefit information, and claims processing accuracy
Comply with organizations internal policies and procedures, Code of Conduct, Compliance Plan, along with applicable Federal, State, and local regulations.
Conduct appropriate research and follow-up for prompt resolution of disputed claims.
Mentors and trains new employees.
Acts as a resource to employees for issues and questions.
Assists the department management with resolving difficult cases.
Identifies and implements policy changes and needs to improve work flow and service.
Maintain a general understanding of the grievances and appeals process according to company policies.
Keep resource information up to date, accurate and organized.
Ensure that HIPAA laws and UHA confidentiality policies are strictly adhered to.
Meet department and company expectations as they pertain to attendance, performance and values.
Development of Standard Operating Procedures, policy and procedures and training of new staff.
Complete special projects and perform other duties as assigned.
Maintain a Customer Satisfaction rating that is in keeping with department standards.
Provide back up for other department staff as necessary.
GUIDING BEHAVIORS
Accountability
Always demonstrate the highest performance and behavior standards. Share responsibility and expect others to be accountable.
Efficiency
Demonstrate a proactive approach to problem identification and solutions. Be innovative and solutions oriented, improving processes while reducing costs. Demonstrate appropriate time-management skills. Optimize the use of available resources.
Be a Team Player
Support and assist your team members. Be available to help, and learn from your team. Keep an open mind to feedback and earn trust of staff.
Integrity
Keep your promises, commitments, and confidences. Be honest and straightforward dealing with all issues fairly and consistently.
Stewardship
Adhere to all state and federal regulations relating to your position including the Health Insurance Portability and Accountability Act (HIPAA), Fraud & Abuse and Occupational Safety and Health Administration (OSHA) laws. Abide by Company policies and procedures at all times.
CHALLENGES
Working with a variety of personalities, maintaining a consistent and fair communication style.
Satisfying the needs of a fast paced and challenging company.
Telephone contact with angry or hostile member.
QUALIFICATIONS
High school diploma or equivalent required.
Associates Degree in business, healthcare, or related field preferred, Healthcare Customer Service Associate Certification by AHIP, a degree in business or healthcare, or equivalent work experience (i.e. 2 years in a customer service oriented field) preferred, or 2 years experience in Customer Care Associate I at UHA.
Computer skills required, including keyboarding and 10-key proficiency, Microsoft Office, Word, Excel, and CRM Software.
Experience should include working in one or more of the following areas: Provider relations, managed care operations (e.g., appeals, grievances, customer service), medical clinic operations, and/or related health care functions.
Experience with oral presentations and developing training materials.
Strong understanding of the Oregon Health Plan and health care insurance preferred.
Strong customer and teamwork focus.
Excellent oral and written communication skills as well as the ability to listen. Bilingual and able to read, write and speak Spanish proficiently preferred.
Ability to handle and resolve difficult situations in a professional manner.
Cultural Competency training preferred.
A strong understanding of Current Procedural Terminology (CPT) and International Classification of Diseases, Tenth Revision (ICD-10) is required.
Exceptional customer service, active listening, and verbal and written communication skills, professional phone voice.
Thorough understanding of services and policies. Demonstrated ability to identify and implement improvements and changes.
Ability to ask prying questions and diffuse tense situations.
Strong time management and decision-making skills.
Adaptability and accountability.
PHYSICAL DEMANDS
Typical office environment requiring standing, sitting, walking, bending, and lifting up to 25 pounds. May be exposed to patient and environment conditions such as unpleasant sights, smells and contagious diseases.
