Customer Service Representative I

Santaclara Family Health Plan - San Jose, CA

Full-time - Entry Level

San Jose, CA

Executive, Legislative, and Other General Government Support

About the position

The Customer Service Representative I answers inbound calls and makes outbound calls to support Customer Service Department operations in a manner that maintains compliance with Medicare and Medi-Cal regulatory requirements and achieves Call Center service-level objectives.

Responsibilities

• Act as the primary point of contact and liaison for SCFHP members and providers contacting the plan regarding general inquiries, concerns or requests for information.
• Develop a general understanding of all member facing materials, communications and interactions and be prepared to respond appropriately to follow up calls.
• Answer inbound calls and/or place outbound calls in a high call volume environment and work directly with members and providers to accurately and completely answer inquiries involving SCFHP program services and benefits.
• Follow established guidelines and resources to respond to member and provider inquiries and resolve concerns in an accurate, timely, professional, and culturally competent manner.
• Intake, handle and coordinate member grievances, appeals and billing issues, escalating to the Grievance and Appeals department, when necessary.
• Educate members and providers on eligibility, and medical and pharmacy benefits and how to access services in a manner that achieves excellent service standards and maintains high customer satisfaction.
• Use listening skills and judgment to appropriately categorize and accurately document all contacts and follow-up actions regarding member and provider communications and activities in accordance with established guidelines.
• Appropriately handle member and provider requests through alternative channels such as e-mail, voicemail, fax, walk-in, etc. in accordance with established procedures.
• Triage member and provider requests or inquiries for other departments.
• Conduct member surveys as assigned in accordance with established guidelines.
• Attend and actively participate in daily, weekly, and monthly departmental meetings, in-services, training and coaching sessions.
• Identify member/provider issues and trends and report relevant information to management.
• Perform other related duties as required or assigned.

Requirements

• High School Diploma or GED.
• Minimum one year of experience in Customer Service or Call Center role, preferably within a Health Care, Public Assistance or Human Services programs.
• Ability to meet Key Performance Indicators by participating in and achieving the standards of the Customer Service Call Center Quality Program.
• Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications, such as Outlook, Word and Excel.
• Ability to use a keyboard with moderate speed and a high level of accuracy.
• Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP Plan members and providers over the telephone, in person or in writing.
• Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes.
• Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position.
• Ability to maintain confidentiality.
• Ability to comply with all SCFHP policies and procedures.
• Ability to perform the job safely with respect to others, to property, and to individual safety.

Nice-to-haves

• Prior experience with managed care plans, Medi-Cal and Medicare programs, and working with underserved populations.
• Spanish, Vietnamese, Chinese, or Tagalog language bi-lingual skills.