Customer Service Representative - St. Luke's Health Plan - 155158

Description

The Customer Service Representative for the St. Luke’s Health Plan is the first point of contact for members, providing outstanding customer service and support. The role involves handling inquiries and assisting with benefit-related questions. Key responsibilities include:

• Handling phone calls, emails, portal inquiries, and social media inquiries with professionalism and courtesy.
• Assisting members with benefit-related questions and inquiries, explaining coverage details clearly and comprehensibly.
• Explaining complex billing statements, EOBs, and claims processing terminology in a clear and understandable manner.
• Providing detailed information on deductible, copayment, coinsurance, and out-of-pocket expenses, helping members understand their financial responsibility.
• Collaborating with the claims department to address discrepancies or concerns regarding claim processing and benefit application.
• Investigating and troubleshooting member issues, resolving problems and concerns within the scope of the role, and escalating to appropriate resources when necessary.
• Escalating complex or unresolved issues to the Customer Service Manager or other designated contacts for additional assistance.
• Documenting all interactions and resolutions accurately and comprehensively in the appropriate systems.
• Educating members on their appeal rights, explaining the process for initiating an appeal or grievance and the timeline for resolution.
• Clarifying the steps involved in the appeals process, including how to submit an appeal, the review and decision-making process, and potential outcomes.
• Adhering to all applicable laws, regulations, and industry standards, including HIPAA guidelines.
• Participating in quality assurance initiatives to ensure accuracy and consistency in customer service and appeals and grievance handling.

Requirements

• Excellent communication skills and a thorough understanding of St. Luke’s Health Plan’s products and services across various lines of business.
• Attention to detail and the ability to handle a variety of member interactions, including phone calls, emails, portal inquiries, and social media inquiries.
• Knowledge of insurance benefits across multiple lines of business, including individual on and off exchange, small group, large group, self-funded, and Medicare Advantage plans.
• Ability to explain coverage details in a clear and understandable manner, helping members make informed decisions about their healthcare coverage.
• Experience in addressing complex billing statements, EOBs, and claims processing terminology.
• Collaboration with the claims department to resolve discrepancies or concerns regarding claim processing and benefit application.
• Problem-solving skills and the ability to investigate and troubleshoot member issues.
• Ability to escalate complex or unresolved issues to appropriate resources.
• Documentation skills to document all interactions and resolutions accurately and comprehensively in the appropriate systems.
• Education on the types of issues that can be appealed, and the documentation required to support an appeal.
• Understanding of the appeals process, including how to submit an appeal, the review and decision-making process, and potential outcomes.
• Compliance with all applicable laws, regulations, and industry standards, including HIPAA guidelines.
• Participation in quality assurance initiatives to ensure accuracy and consistency in customer service and appeals and grievance handling.