Operations Specialist -10
ABCBS - Little Rock, AR

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This position reports directly to the Medicare Products Operations Manager.

The incumbent must be able to resolve escalated customer service issues and assist in administering all aspects of the different Medicare Products operations. He/She is responsible for maintaining good working relations with all company and contracted vendor personnel and must be capable of understanding and interpreting benefit plans and operational processes. The incumbent acts as a liaison between all support functions and the member/provider. This includes researching problems and inquiries, using various in-house and vendor software applications and providing appropriate responses with correct information. Appropriate information may include responding to customer complaints, preparation of periodic reports/data, information, and summaries to management with appropriate documentation.

Nature & Scope
The Medicare Products Operations area has responsibility for the development and delivery of Medi-Pak Rx products and Medi-Pak Advantage products including MA-PD and MA only services that meet the benefit needs of our customers and contribute to the profitability of the enterprise. Services must be provided correctly and in a timely manner in order to maximize member satisfaction and plan performance.

The incumbent is part of a team responsible for maintaining good relations with all members, providers, vendors and Plan personnel in a friendly and courteous manner. The incumbent will have extensive knowledge of Arkansas Blue Cross and Blue Shield, Medi-Pak Rx, and Medi-Pak Advantage membership and enrollment guidelines.

The Medicare Products Operations Specialist has the authority to make decisions as related to inquiries received from Medicare, members, health care providers and internal and external sales staff; to implement measures necessary to resolve problems and to communicate a response orally or in written form to the inquirer.

Minimum Job Requirements
High school diploma (or equivalent).

College course work preferred.

Experience in specialized customer service with experience in a health environment.

Experience working with personal computers (Word, Excel, etc.).

Excellent analytical and reasoning skills.

Progression Criteria

Grade 11 Upgrade

An employee will be moved to Grade 11 when the following criteria have been met consistently for six months as determined by the supervisor with manager approval.

Representative must have completed Service Excellence, Business Writing, Grammar and Medical Terminology Course and applied principles and skills in daily contact with internal and external customers.

Representative has demonstrated necessary technical/professional knowledge to make sound decisions, render judgment, take action, and perform the job without constant supervision.

Representative demonstrates leadership skills:
  • a. Above average decision making skills
  • b. Above average initiative
Ability to make PowerPoint presentations as required.

Proficient knowledge of appropriate systems.

If required, individual must be able to travel with occasional over-night stays.

Representative's supervisor must have received no consistent and substantiated negative feedback from customers within the previous 6-months.

Must currently be meeting all divisional performance standards and requirements for current grade.

Representative must not have been placed on written warning in the previous 12 months.

Security Requirements
This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual.

Segregation of Duties
Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.

Resolve escalated customer service inquiries when Medicare, members, providers and internal and external sales staff are unable to reach resolution through contracted vendor customer service areas.
Assist with specific operational situations that would produce accurate and efficient processing of medical and pharmacy claims and assist in correcting deficiencies relating to operation of the Medi-Pak Rx or Medi-Pak Advantage claims, enrollment and billing systems.

Pro-actively educate internal and external customers regarding Medi-Pak Rx or Medi-Pak Advantage benefits, programs, and procedures.

Train as back-up on all operational aspects of Medi-Pak Advantage and Medi-Pak Rx programs conducted within the department.

Receive and appropriately handle correspondence.

Answer a high volume of telephone calls from internal and external customers and resolve issues.

Set up and train internal users for inquiry access on the contracted vendors’ claims and eligibility systems

About this company
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In 2012, Arkansas Blue Cross was named one of central Arkansas’ “Top Work Places” by the Arkansas Democrat-Gazette and...