Call Center Representative

Job Title: Call Center Representative
Location: Houston, TX 77401 (Onsite)
Duration: 03+ Months (Extension Possible)
Shift: Candidates must be able to work an 8-hour shift during the department operation hours, which are 7 am - 6 pm (Monday - Friday)

Job Description:
Summary:
To serve as a member and/or Provider Advocate by possessing knowledge and understanding of the organization's processes, policies and procedures in order to investigate, resolve and/or facilitate resolution of simple to moderately complex issues and/or questions reported by Client members, prospective members, healthcare providers, or other entities relating to Client Managed Care Organization. To be the first point of contact for assistance or information regarding eligibility, benefits, authorizations, claims, referrals and/or any other Member/Provider needs. To assist and advocate for Members and/or Providers throughout the complaint and appeal process. To assist Members with timely appointment scheduling. Responsibility A: Supports the Health Plan call centers day to day operations.

• Handles calls from Members/Providers seeking assistance with Member and/or Provider related issues. Reviews systems to
• identify issues, comprehensively researches the issues, collaborates with other departments, communicates with internal and external resources, and creates appropriate responses.
• Acts as a liaison and advocate for the Members/Providers.
• Gathers information to support decisions or recommendations for action needed to resolve Member/Provider questions, issues, and/or concerns.
• Assists with real-time resource management.
• Interacts tactfully and empathetically with Members/Providers.
• Ensures HIPAA protections are in place by verifying the identity of all callers prior to disclosing Personal Health Information (PHI).
• Completes all assigned work queue tasks and/or after hour call center vendor notifications.
• Completes necessary documentation thoroughly, accurately, and timely in Client or Client systems e.g. MACESS or EPIC when applicable.
• Alerts team leader of any issues or concerns that require escalation for complete resolution or which may indicate a larger underlying problem.
• Bilingual candidates only please: English/Spanish

Pre-Screening Questions:

1. Do you have at least 12 years of call center experience? If yes, in what setting?
2. Have you worked for a health plan or managed care organization? If yes, which one and in what role?
3. Do you have experience supporting Medicaid members? Please describe.
4. Are you familiar with explaining medical benefits, eligibility, and coverage limitations to members?
5. What call center metrics were you held accountable to? (Examples: AHT, adherence, QA, FCR.)
6. Are you comfortable handling high call volumes and speaking with upset members?
7. What systems have you used? (Epic, CRM, claims platforms, eligibility systems, etc.)
8. Why are you interested in working on a Medicaid member hotline?

Skills:

• Knowledge of managed care, customer service, call center desktop support applications, and general computer literacy.
• The ability to work well with the public and adopt a customer perspective and work well individually and in a team environment
• Effective interpersonal skills and phone etiquette are required
• Strong verbal communication skills
• Good listening skills
• Knowledge of medical terminology
• Problem identification and problem-solving skills and able to multitask
• Technical Skills: Typing, 35 WPM
• Bilingual (English Spanish) preferred

Education:

• H.S. Diploma or GED - Required
• 1 year - Customer service experience within managed care or insurance industry or Call center experience in any industry - Required