High school diploma plus one to three years office/business experience, call center experience preferred and/or claims processing experience preferably in managed care with possible enrollment experience Demonstrated ability to communicate effectively in person and via telephone with members, employer groups, brokers, physicians, physician office staff. Written communication skills as well as business writing and presentation skills are required. Requires strong organizational skills, ability to create, sort and analyze reports (Excel, Access, etc) and system processes. A thorough knowledge of reimbursement methodologies i.e. DRG, Relative Value Systems, Per Diem, Fee schedule, Capitation, etc and some knowledge of risk sharing programs helpful. Some knowledge of CRM and EPIC as well as any other databases that may be used PHS Enterprise wide. Demonstrated ability to function effectively as a team member. Requires ability to retain plan details and basic medical terminology.
Primary Job Functions
- Responsible for providing customer service for patients in regard to the triage of patients, scheduling appointments, referrals, messaging, and maintaining patient demographics.
- Respond to incoming calls routed through skill-based technology to meet quality standards and performance measurements. Is ready to take calls at the scheduled time, and spends the appropriate amount of time taking calls throughout their shift to resolve contacts on initial encounter. Conducts outbound calls as required and meets established quality/quantity guidelines supporting PHS/PHP/PMG initiatives and/or programs.
- Develop and maintain positive customer or partner relationships. Acts as member/patient advocate in dealing with practitioners, employer groups, and brokers. Maintains prescribed standards of quality in all research, customer and partner contacts/service functions and promotes customer satisfaction/loyalty through quality contact and timeliness of responses, achieves quality audit results as required.
- Assists in the development of documentation of process and procedures into functional process improvements to enhance overall level of service to our customers and partners. Uses the Improvement model, identifies patterns in call inquiries/grievances, conducts root cause analysis in resubmitted and adjusted claims and reports to management team.
- Researches inquiries/special projects as requested and responds to customer, partner or other PHS/PHP business units to ensure accuracy of benefit interpretation with results of research and resolution and within required timelines. Responses to customer or partners to be done using Microsoft Word, Excel or similar databases when appropriate. Uses available documentation such as D.A.R.T., Provider Manual, Pres Online, and Policies and Procedures to analyze and provide accurate and consistent information and benefit interpretation.
- Participates as an effective and active team member both individually and in a team environment. Participates in a value-added manner as a team member to internal teams as well as other process improvement teams (i.e. QCC) and initiatives.
- Record all calls, mail, email, faxes, walk-in encounters, etc. in appropriate databases to provide meaningful, accurate data for analysis and reporting.
- Assist in coordinating (when necessary) meetings with customers or partners for training, contracting, and reporting.
- Perform other functions as required.
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