[Remote] Customer Care Representative I - SHP Customer Service - Telecommuter - Day Shift - Full Time

Note: The job is a remote job and is open to candidates in USA. Sharp HealthCare is seeking a Customer Care Representative I to facilitate communication between the Plan and its members, providers, and other stakeholders. This role involves providing information about Plan products, resolving concerns, and maintaining accurate records of customer interactions.ResponsibilitiesResponsible for direct and timely communication between the Plan and Plan members, potential members, providers, employer groups, brokers, internal departments and external agenciesMaintains high level of knowledge regarding Plan products, premiums, benefits and proceduresUses knowledge and judgment to select appropriate resources for assisting callersProvides information on all aspects of Plan products, premiums, benefits, policies and proceduresResponsible for accurate problem-solvingResearches and resolves concernsAccess patient data Documents all calls in the IDX Customer Service Module immediatelyVerifies prescription drug eligibility, benefits, claims, and authorizations in PBM's MedAccess systemAdds and updates member information in the MedAccess systemMaintains current knowledge of IDX system modules for Registration, Enrollment, Claims, Utilization Management and Premium BillingVerifies enrollment, benefits premiums and other individual and group information in SalesforceGenerates member letters using GlobalworksRetrieves member documents stored in OnBaseUses SharpConnect to assist members with online inquiresAbility to understand and resolve common Commercial member inquires/complaints by phoneProvides prompt, accurate and excellent services to internal and external customersDevelops solid professional working relationships with various internal departments and units and, as required, vendors, providers, employers, brokers and/or other customersWorks collaboratively with other Plan and medical group departments to address customer questions and concerns, including Health Services, Enrollment, Claims Research, UnderwritingWorks collaboratively with health care providers and office staff to facilitate access to careMaintains a complex and evolving knowledge of health insurance and health care reform mandatesParticipates in special projects and other duties as assignedAssists new and existing members in attaining a workable understanding of their health coverage, clarifies terminology in enrollment materials, and instructs members regarding how to utilize the services of the Plan and the provider networkAnswers inquiries from potential members, members, brokers, employer groups, State and County representatives, Plan providers, internal departments, and all other callers, including: a) Verification of eligibility, enrollment and PCP assignment; b) Benefit, co-payment, and referral questions; c) Requests for PCP changes, address changes, ID cards, benefit materials; d) Inquiries regarding premium and subsidy amounts and balances; and e) Clarification of conversion, COBRA, and Cal-COBRA enrollment procedures, including quotes of approximate ratesDocuments member concerns, complaints, and appeals, and forwards to the appropriate Customer Care Lead or Supervisor on a daily basisIf unable to provide immediate assistance, promptly returns calls with answers and resolutionsUtilizes appropriate handbooks, Evidence of Coverage, supplemental benefit information, and other reference material as needed to quote Plan benefits, exclusions, and policiesMaintains detailed knowledge of required materials and resources, including: a) Operations policies and procedures b) All Combined Evidence of Coverage (Member Handbooks) and Employer Group Benefit Agreements c) Language LineInforms and works collaboratively with other Plan departments, in areas including but not limited to: a) Forwarding prospects for new brokers or employer groups to Marketing; b) Working with Health Services regarding authorization requests and assistance for special need cases; c) Forwarding potential provider education issues to Provider Relations; d) Documenting potential member fraud, COB, and third party liability issues, and reporting to the appropriate department; and e) Documenting requests for additions to the provider network and forwarding to ContractingAssists members with premium and billing questionsProcesses ACH and credit card payments over the phoneUses appropriate resources to describe and recommend plan options to individuals interested in purchasing Sharp Health Plan coverageIdentifies and recommends solutions for operational problems to ensure continued high quality service to internal and external customersMaintains an organized work areaEffectively utilizes a wide range of reference materialsDemonstrates knowledge of specific enrollment, benefit, and premium information for commercial (group and individual) and Medicare productsComplies with regulatory and accreditation requirements and timelines for customer service including DMHC, CMS, and NCQAWorks with moderate supervision on projects assigned by Customer Care Supervisor, including but not limited to: New member orientation; Premium billing reminders and payment processing; Member education; Member claims investigation and resolution; Pharmacy prior authorizations and eligibility; Member appeal/concern investigation and documentation; Member reimbursement requestsMaintain overall scorecard score of 3.0 or higher for 6 consecutive monthsMeet or exceed in all scorecard metrics for 6 consecutive monthsBehavior Standards - Average Score of 8 or higher within a 12 months periodAttendance - No more than 2 unscheduled occurrences within a 12 months periodKnowledge - Customer Care Commercial Knowledge Assessment score of 80% or aboveSkillsH.S. Diploma or EquivalentLess Than 1 Year Minimum of six (6) months experience as a Customer Call Center RepresentativeAssociate's Degree Business administration or health care administration (including courses of study in accounting, finance, marketing, and health care administration)2 Years Customer service or medical office experience1 Year Experience working full time as SHP Customer Care Temporary CCR IMedical office certification, to include medical terminology, preferredBilingual preferred but not requiredCompany OverviewSharp HealthCare is a not-for-profit integrated regional health care delivery system based in San Diego, Calif. It was founded in 1955, and is headquartered in San Diego, California, USA, with a workforce of 10001+ employees. Its website is http://www.sharp.com.