Member Service Representative Level 1 (San Jose, CA)

Member Service Representative Level 1 (San Jose, CA)

This is a call center environment. Call center experience is required. The Member Service Representative responds to incoming telephone calls from client participants and providers with questions about Health & Welfare benefits. This is a Union position.

Essential duties and responsibilities include but are not limited to:

• Positively respond to incoming calls from members and providers by, among other things:
• Explaining group benefits
• Addressing eligibility questions
• Providing information on referrals
• Describing required authorizations for medical care
• Assisting with claims' issues
• Providing claims' status
• Answering questions or concerns
• Resolving problems
• Submit requests for adjustments on claims, research questions and problems, and provide the best solutions available.
• Alternate with co-workers during slow periods to make sure phones are always covered.
• Make outgoing calls to members and providers.
• Alpha sorting, organizing, or other special projects.
• File forms and letters.
• Provide available information upon request and escalate issues as appropriate to Supervisor and/or Manager.
• Retain records of calls by documenting in the appropriate system for tracking.
• Other duties may be assigned.
• Reliable and predictable attendance is an essential function of this job.

Member Services Representative Levels:

• Level I - Some customer service experience, some claims knowledge, good phone skills, positive attitude, medical knowledge a plus.
• Level II - Level I skills, plus complete understanding of BeneSys, Eldorado, Benefit Driven, Well Point, and Envision systems and Plan documents. Knowledge of any vendor systems that may be required to assist in calls. Ability to field 90% of calls without consulting the Unit Leader.
• Level III - Level I and II skills, plus complete understanding of all California Plans. Knowledgeable in handling group benefit issues, ability to interpret Plan guidelines. Ability to analyze plans and interpret benefit language contained in Plan documents. Good overall understanding of claims' processing guidelines to assist with resolving claims' issues and able to translate these issues clearly for resolution. Good internal technical ability to assist other Team members with internal/external systems. Fielding elevated issues from the Team and assessing the problem and attempting to resolve them prior to referring to the Supervisor or Manager.

Qualifications:

• Background in medical claims processing.
• Call center experience.
• Knowledge of medical terminology and understanding of healthcare benefits, definitions and applications.
• Knowledge of and capable of handling multiple group benefits.
• Ability to communicate clearly with accurate information to callers either by telephone, electronic messaging, or face-to-face interaction.
• Ability to deal with people in stressful situations.
• Ability to use good communication skills and keen observation to understand what a caller is asking for and then use good judgment to come to a resolution.
• Ability to multi-task, respond to questions correctly and accurately and resolve the issue from initial contact with caller.
• Ability to diffuse irate calls to a level where the caller is satisfied with the response and resolution is complete.
• Ability to work well in a team environment and independently.
• Good working knowledge of Microsoft Excel/Word.
• Regular and predictable attendance is an essential function of this job.

Education and/or Experience - High School diploma or GED equivalent. 2 plus years in an Employee Benefits position or similar.

Language Skills - Effective communication skills are essential. Individual should enjoy and be able to work in a busy and sometimes noisy/high pressured environment.

Mathematical Skills - Ability to apply concepts of basic addition, subtraction, multiplication, and division.

Reasoning Ability - Representative must be analytical and can apply common sense to carry out detailed written or oral instructions. Representative must be able to deduce if a balance due is the responsibility of the member or if the plan has yet to consider the charges.

Physical Demands - Occasional lifting of paperwork and batches of claims. Regular use of standard office equipment such as computers, phones, photocopiers, fax machines, etc. Sustained periods of being on the telephone, keyboarding, sitting/standing.

Work Environment - The position operates in a typical call center environment, that, at times, can be noisy, pressured and stressful. The department can be fast paced.

Work Schedule - Full time. Monday Friday, 8:00am - 4:30pm. Required in office (no at-home days).

Competitive Benefits:

• Medical/Dental/Vision, with option for dependent coverage
• Flexible spending accounts
• Company-paid basic life/AD&D, short-term disability, long-term disability insurance
• 15 days Paid Time Off during first full calendar year
• 11 paid holidays
• Up to 5 days of paid bereavement leave
• Up to 20 days of paid jury duty leave
• 401(k) with employer match

Pay: The current starting rate for this position is $34.12. This is a union position. The wage rate for this position is determined by the collective bargaining agreement and may be dependent on experience, skills, education and other business factors.

Our Culture:

• Collaboration: working together across 31 locations to achieve the best for the company and our clients
• Dedication: striving to create an environment where all employees work toward a common goal while committing to providing the best customer service to our members and our colleagues
• Integrity: doing what we say we will do. Upholding strong ethical and moral principles

ADA & EEO Reasonable accommodations will be made so that qualified individuals with disabilities are able to complete the application process and, if hired, fulfill the essential functions of their job.