Customer Service Representative - St. Luke's Health Plan

Overview:

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 Customer Service Representative will handle inquiries and assist with benefit-related questions. This role requires excellent communication skills, attention to detail, and a thorough understanding of the St. Luke's Health Plan's products and services across various lines of business.

Responsibilities:

Serves as the primary point of contact for members contacting the call center with inquiries, concerns, or requests for assistance. Listens actively to members' needs and concerns, demonstrating empathy and understanding, and provides accurate and timely information and assistance. Handles a variety of member interactions, including but not limited to phone calls, emails, portal inquiries, and social media inquiries, with professionalism and courtesy.

Utilizes 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, to assist members with benefit-related questions and inquiries. Explains coverage details in a clear and understandable manner, helping members make informed decisions about their healthcare coverage.

Assists members in understanding how their medical claims were processed and how their insurance benefits were applied. Explains complex billing statements, EOBs (Explanation of Benefits), and claims processing terminology in a clear and comprehensible manner. Provides detailed information on deductible, copayment, coinsurance, and out-of-pocket expenses, helping members understand their financial responsibility. Collaborates with claims department as needed to address any discrepancies or concerns regarding claim processing and benefit application.

Investigates and troubleshoots member issues, resolving problems and concerns within the scope of the role, and escalating to appropriate resources when not. Escalates complex or unresolved issues to the Customer Service Manager or other designated contact for additional assistance with resolution. Documents all interactions and resolutions accurately and comprehensively in the appropriate systems.

When appropriate, educates members on their appeal rights, explaining the process for initiating an appeal or grievance and the timeline for resolution. Provides education on the types of issues that can be appealed, and the documentation required to support an appeal. Clarifies the steps involved in the appeals process, including how to submit an appeal, the review and decision-making process, and potential outcomes.

Adheres to all applicable laws, regulations, and industry standards including HIPAA guidelines.

Participates in quality assurance initiatives to ensure accuracy and consistency in customer service and appeals and grievance handling, including HIPAA guidelines.

Stays informed about changes in healthcare regulations, insurance policies, and industry trends through ongoing training and professional development opportunities.

Perform other duties and responsibilities as assigned.

Minimum Qualifications:

Education: High School diploma or equivalent

Experience: 0 years relevant experience.

Licenses/Certifications: None

Permanent