The Customer Care Specialist (CCS) works in the MDwise call-center to serve as the initial and primary contact source for all MDwise members and providers, in addition to being the primary dedicated Customer Care Representative (CCR) for individual escalated issues from Delivery Systems. The position acts as a liaison between members, network providers, external agencies, and MDwise.
- Answer direct calls from providers, Deliver System Provider Relations staff, Care Managers, Quality Managers, and/or Delivery System Administrators.
- Work directly with providers and Provider Relations staff at the delivery system level to solve complicated and ongoing issues, conduct research to arrive at the best resolutions, and document conversations and actions taken.
- Establish a strong working relationship with Provider Relations staff at the Delivery Systems, such that their issues are resolved in a satisfactory manner with no need for escalation.
- Receive incoming telephone calls and conduct personal conferences with members and network providers.
- Provide prompt, courteous, and accurate responses to inquiries and concerns as defined by organizational standards.
- Educate members regarding their benefits and instruct on how to correctly utilize the managed health care system.
- Educate members regarding their rights and responsibilities.
- Serve as the member’s and/or provider’s advocate to resolve outstanding issues.
- Recognize potential quality issues and processes information accordingly.
- Recognize and responds to the inquiries and concerns of the covered members.
- Perform resolution, follow-up, and documentation of member inquiries, grievances/complaints, appeals, requests, and concerns.
- Document all contacts with members in the appropriate system for the purposes of continuity of care and service and update member information as appropriate.
- Process Primary Medical Provider (PMP) changes within the MDwise network.
- Establish a direct working relationship with Delivery System providers.
- Perform other duties as assigned.
Knowledge, Skills, and Abilities:
- Ability to communicate effectively with health plan members, staff, healthcare providers and social service providers.
- Ability to effectively and professionally communicate orally and in writing.
- Demonstrated ability to compose responses to incoming e-mails from providers and Delivery System staff.
- Excellent listening skills.
- Exceptional analytical skills to help ascertain how MDwise can best serve each member.
- Ability to establish and maintain effective working relationships with members/clients, staff (to include Delivery System staff), management, providers, and the public.
- Excellent organizational skills.
- Excellent computer skills including keyboarding, Microsoft Excel, Microsoft Word, Microsoft Outlook, and the ability to learn additional databases/programs.
- Excellent knowledge of myMDwise web portal, as well as familiarity of links on www.mdwise.org.
- Ability to diagnose and research claims issues with internal MDwise staff (Provider Relations and Claims Research Specialists).
- Proven ability to follow up and resolve all escalated issues working with all appropriate internal and external departments and vendors.
- Ability to research and explain inappropriate PMP assignments and discrepancies with State eligibility lookup and MDwise web portal.
- Ability to recognize underlying issues related to immediate problem and ability to solve them.
- Familiarity with individual Delivery System procedures and practices.
- Familiarity with complexities of Panel Add policy.
- Familiarity with complexities of Provider Request for Member Reassignment process.
- Familiarity with transportation policies and ability to respond immediately and effectively to urgent transportation needs.
Minimum Qualification, Training, and Experience:
- Consistently scores above expectations in meeting Core Competencies, Job Responsibilities, and MDwise Goals.
- Minimum of a high school diploma; Associate or Bachelor’s degree preferred.
- 1-2 years of experience in MDwise Customer Service setting preferred.
- 1-2 years of healthcare experience required; will consider Bachelor’s degree in lieu of healthcare experience.