Customer Service Representative

POSTED: April 16, 2025 POSITION: Customer Service Representative DEPARTMENT: Operations/Customer Service BASE RATE: $17.09 per hour, with potential for additional compensation based on qualifications.

POSITION SUMMARY: Provides customer service for members and providers in a positive and professional manner.

Effectively interacts with the operations team, other internal departments, and business partners.

Engages in inbound and outbound calls, routes information to appropriate persons/departments, and resolves member issues.

Ensures comprehensive and accurate data is entered into applications as required.

ESSENTIAL DUTIES AND RESPONSIBILITIES: 1.

Follows all established UPHP policies and procedures, objectives, safety standards, and sensitivity to confidential information.

2.

Meets established production and call performance metrics and ensures a positive customer service experience for members and providers.

Documents all member and provider correspondence in the claims management database.

3.

Assists members of all UPHP product lines with questions about benefits, policies, eligibility, medication denials, participating providers, and accessing care.

4.

Assists members of all UPHP product lines in filing and/or resolving complaints, grievances, and appeals.

5.

Assists providers with eligibility and benefit questions and any member medication issues and routes information as appropriate; provides information related to grievances/appeals.

6.

Assists pharmacy providers with eligibility questions and provides information on pharmacy benefits, medication denials, medication appeals, and routes information to the pharmacy department as necessary.

7.

Stays informed on UPHP, Medicaid and Medicare policies and processes impacting UPHP lines of business and beneficiaries, as well as pharmacy formulary updates and website changes.

8.

Works closely with clinical services, claims, and transportation regarding authorizations, referrals, pre-notifications, benefit exceptions, and projects that benefit the organization.

9.

Processes incoming release of protected health information documentation.

10.

Facilitates routine and ad-hoc member outreach as directed by the customer service supervisor or manager.

11.

Acts as back up to the Receptionist as needed.

12.

Supports National Committee for Quality Assurance (NCQA) Health Plan accreditation standards.

13.

Maintains confidentiality of client data.

14.

Performs other related duties as assigned.

POSITION QUALIFICATIONS: Education: Minimum: High School Diploma or GED Preferred: Associate in business administration, healthcare administration, or related field Experience: Minimum: Two (2) years of general customer service or call center experience Preferred: Two (2) to three (3) years of customer service experience in healthcare, health insurance, or related; experience in call documentation and data entry into Customer Relationship Management (CRM) systems or similar platforms; experience with healthcare management software is highly preferred.

Required Skills: Keyboarding proficiency Strong interpersonal and team collaboration skills Working knowledge of MS Office (Word, Excel, and PowerPoint) Digital dexterity Exceptional customer service skills, problem-solving skills, and telephone etiquette Excellent human relations and oral/written communication Excellent organization and attention to detail Composition and proofreading abilities Desirable Skills: Oriented to managed care or healthcare systems Basic knowledge of medical terminology Skilled in managing conflict and facilitating positive outcomes The qualifications listed above are intended to represent the minimum skills and experience levels associated with performing the duties and responsibilities contained in this job description.

The qualifications should not be viewed as expressing absolute employment or promotional standards, but as general guidelines that should be considered along with other job-related selection or promotional criteria.

Physical Requirements: [This job requires the ability to perform the essential functions contained in the description.

These include, but are not limited to, the following requirements.

Reasonable accommodations may be made for otherwise qualified applicants unable to fulfill one or more of these requirements]: Ability to enter and access information from a computer Ability to access all areas of the UPHP offices Occasionally lifts supplies/equipment Prolonged periods of sitting Manual dexterity Working Conditions: Works in office conditions Fast-paced working environment Subject to many interruptions