Medicare Customer Service Professional
Company: Cambia Health Solutions, Inc
Posted on: March 14, 2023
Medicare Customer Service Professional IRemote within ID, OR,
WA, or UT. Candidates outside of these states will not be
considered.Starting pay range $16.20 - $20.10 DOE and Location. HR
will reach out and provide specific information.We will be
conducting verification of employment on your current and past
employment if selected to hire. Please make sure you are applying
with the most updated resume with correct dates of
employment.Primary Job Purpose:The Customer Service Professional I
provides information, education and assistance to members,
providers, other insurance companies, attorneys, agents/brokers or
other customer representatives on recorded phone lines regarding
benefits, claims and eligibility. They also provide excellent and
caring services to all internal and external members and providers.
The Customer Service Professional I is likely to be the primary
contact between the corporation and members and providers. The
manner in which a member or provider is treated during that contact
is critical to retaining our customers and to the overall success
of the corporation.Responsibilities:
- Successfully complete training period and meet dependability,
timeliness, accuracy, quantity, and quality standards as
established by department. Study, review and learn information,
procedures and techniques for responding to a variety of
- Communicate with a variety of subscribers, providers,
healthcare providers, agents/brokers, attorneys, group
administrators, other member representatives, internal staff and
the general public with inquiries regarding benefits, claim
payments and denials, eligibility, decisions, and other information
through a variety of media - oral, written and on-line
communications. Respond to multiple inquiries on all designated
lines of business.
- Quickly and accurately assess provider and member inquiries and
requirements by establishing a rapport inquirer in order to
understand his/her service needs. Identify errors promptly and
determine what corrective steps may be taken to resolve
- Apply benefits according to appropriate contract. Determine
benefit payments, maximum allowable fees, co-pays, and deductibles
from appropriate contracts.
- Make appropriate corrections of denied, process-in-error or
- Explain benefits, rules of eligibility and claims payment
procedures, pre-authorizations, medical review and referrals, and
grievance/appeal procedures to members and providers to ensure that
benefits, policies and procedures are understood.
- Educate members and providers on confusing terminology and
policies such as eligible medical expenses, hold harmless, medical
necessity, contract exclusions and limitations, and managed care
- Maintain confidentiality and sensitivity in all aspects of
internal and external contacts.
- Manage high volume of calls on a daily basis, prioritize
follow-through and document member and provider inquiries and
actions on tracking system and/or by completing logs. May generate
written correspondence and process document requests.
- May provide face-to-face member and provider service and
education in a lobby setting or walk-up counter using a PC. Assist
individual, Medicare and other applicants in completing their
applications and answering any questions they may have. When
required, may maintain a cash drawer and ensure that it balances
- Maintain files/records of constantly changing information
regarding benefits/internal processes including company-wide
internal policies and benefit updates for new or existing business.
Work is subject to audit/checks and requires considerable accuracy,
attention to detail and follow-through.
- Comply with NMIS/MTM and Consortium standards as they relate to
the employee's responsibility to meet BlueCross BlueShield
Association (BCBSA) standards and corporate goals.
- Assist in identifying issues and trends to improve overall
- For HMO related work: Enter, correct and adjust referrals
according to established policies and procedures. Explain referral
rules, processes to providers and internal customers.Minimum
- Government Programs related jobs, demonstrated thorough
knowledge of State and Federal regulations.
- Keyboarding skills of 30 wpm with 95% accuracy.
- Proficient PC skills and prior experience in a PC
- Demonstrated knowledge of medical terminology and coding
- Ability to apply mathematical concepts and calculations.
- Ability to communicate effectively orally and in writing with
understanding and ability to apply correct punctuation, spelling,
grammar and proof-reading skills.
- Demonstrated ability of strong customer-service skills,
including courteous telephone etiquette.
- Ability to make decisions and exercise good judgment in a
complex and rapidly changing environment.
- Ability to adapt to a fast-paced environment and learn, retain,
and interpret new or evolving information, procedures, and policies
and communicate them effectively.
- Ability to work under stress and pressure and respond to
inquiries with tact, diplomacy and patience.
- Ability to work in a team environment.
- Ability to exercise discretion on sensitive and confidential
- Demonstrate initiative in researching and resolving benefit,
and eligibility issues.Normally to be proficient in the
competencies listed above:Customer Service Professional I would
have a high school diploma or equivalent and 1 year customer
service call center experience or 1 year customer service
experience such as insurance, retail, banking, restaurant, hospital
medical office or other experience with extensive customer service
contact or equivalent combination or education and experience.Work
- Work primarily performed in office environment.
- May be required to work overtime.
- May be required to work outside normal hours.
Keywords: Cambia Health Solutions, Inc, Salem , Medicare Customer Service Professional, Hospitality & Tourism , Salem, Oregon
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