Customer Care Representative – Day Shift
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Job Description
Customer Care Representative supporting members of Sharp Health Plan, a San Diego healthcare system. Resolving coverage, claims, billing, enrollment, and provider-network questions through phone and digital systems.
Responsibilities:
- Communicate directly and promptly with Plan members, potential members, providers, employer groups, brokers, internal departments, and external agencies
- Provide information about Plan products, premiums, benefits, policies, and procedures
- Research and resolve customer concerns accurately
- Document calls and member concerns, complaints, and appeals
- Verify eligibility, enrollment, benefits, claims, authorizations, premiums, and PCP assignments using IDX, MedAccess, Salesforce, and related systems
- Add and update member information and generate or retrieve member documents
- Answer inquiries about benefits, referrals, PCP changes, ID cards, premium and subsidy amounts, COBRA, and Cal-COBRA procedures
- Assist members with coverage understanding, enrollment materials, provider-network services, premium and billing questions
- Process ACH and credit-card payments by phone
- Collaborate with internal departments, healthcare providers, vendors, employers, brokers, and other customers
- Participate in special projects, work groups, proposals, audits, and departmental backup support
- Identify and recommend solutions to operational problems
- Comply with DMHC, CMS, NCQA, regulatory, and accreditation requirements
- Work on assigned projects including member orientation, billing reminders, member education, claims investigation, pharmacy authorizations, appeals, and reimbursement requests
Requirements:
- High school diploma or equivalent
- Minimum of six months’ experience as a Customer Call Center Representative
- Basic computer and writing skills
- Demonstrated knowledge of Plan benefits, policies, and procedures
- Knowledge of health maintenance organizations, performance management, and customer satisfaction assessment and delivery
- Mature and sound judgment
- Superior interpersonal skills
- Ability to effectively participate in Customer Care activities
- Bilingual skills preferred but not required
- Medical office certification, including medical terminology, preferred
- Must meet department scorecard, behavior, attendance, and knowledge-assessment standards
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