Customer Service Representative I

Purpose of Position:

The Customer Service Representative I handles calls from customers to resolve, educate, follow up, and respond to questions regarding California Choice/Choice Builder plan administration and procedures groups, members, brokers, and general agencies.

Essential Functions:

• Understanding of company policies and procedures as they apply to California Choice/Choice Builder plans.
• Answers questions by telephone from groups regarding new hires, billings, rates, supplies, administrative procedures, etc.
• Educates, via telephone, employees/dependents regarding PCP’s, ID cards, RX problems, administrative procedures, dependent coverage, address changes, etc.
• Follows-up on calls and emails from brokers regarding problems that their groups are experiencing with providers.
• Ability to interact with brokers, general agents and sales representatives on a daily basis and must be able to answer questions regarding California Choice processes.
• Responds to calls from providers to confirm eligibility and benefits.
• Verifies enrollments and resolves issues with carriers.
• Expedites the processing of members' enrollment with the carrier if urgent services are needed.
• Review and submit appeal requests from groups.
• Review /Audit group billing and explain to clients in a clear and accurate manner.
• Document calls in the call tracking system.
• Departmental standard requires each Customer Service Representative to provide Service of Unequalled Excellence to all callers by maintaining an average of 90% or greater on Call Reviews.
• Answer at least 100% of the daily call volume average.
• Provide clear and explicit documentation while maintaining percentage at a level of 90% or higher daily.
• Make busy time of 20 minutes or less per day.
• Meet department standards for quality and quantity of work.
• Meet department and team standards for turnaround times.
• Adhere to all HIPAA (Health Insurance Portability and Accountability Act) and PHI (Personal Health Information) guidelines.
• On-site regular attendance and punctuality are essential functions of the job.
• Performs other business tasks or functions as assigned.

Knowledge, Skills & Abilities Required:

• At least two (2) years of customer service experience preferred.
• Knowledge of the health insurance industry and customer service experience preferred.
• Ability to handle irate customers in a courteous, patient, calm, and positive manner while maintaining a high quality and quantity of work.
• Experience in handling high call volume.
• CA Life & Health license required. If a successful applicant does not have an insurance license, it is required to obtain one within six (6) months of the date of hire.
• Must have excellent verbal and written communication skills, especially under pressure.
• Must be computer literate in Microsoft Word, Excel, and Outlook. Accurate data entry skills are a must. Typing at 55 WPM or more.
• Must be able to work in a fast-paced environment where deadlines are a priority and handle multiple assignments simultaneously.
• Problem-solving skills required.
• Must have a proficient knowledge of the English language.
• Proficient knowledge of the Spanish language is a plus. If hired as a Bilingual representative, Language Assistance Certification is required every two (2) years.

Educational Requirements:

• High school diploma or equivalent required.

Physical Requirements:

Must be able to sit for extended periods of time and occasional standing and walking. Must have adequate hearing for phone work. Vision requirements include close vision and the ability to adjust focus. Must be able to communicate effectively in English. Must be able to use a keyboard and other office equipment. Ability to lift up to 10 pounds occasionally.