Customer Care Specialist

Customer Care Specialist

Our work matters. We help people get the medicine they need to feel better and live well. It fuels our passion and drives every decision we make. This position is a front-line service position providing assistance to members and providers regarding programs, policies, and procedures. Responsibilities include answering incoming calls related to eligibility, benefits, claims and authorization of services from members or providers. Responsibilities also include the administration of intake documentation into the appropriate systems. Overall expectations is to provide outstanding service to internal and external customers and strive to resolve member and provider needs on the first call. Performance expectations are to meet or exceed operations production and quality standards.

Responsibilities :

• Actively listens and probes callers in a professionally and timely manner to determine purpose of the calls.
• Researches and articulately communicates information regarding member eligibility, benefits, EAP services, claim status, and authorization inquiries to callers while maintaining confidentiality.
• Resolves customer administrative concerns as the first line of contact - this may include claim resolutions and other expressions of dissatisfaction.
• Assists efforts to continuously improve by assuming responsibility for identifying and bringing to the attention of responsible entities operations problems and / or inefficiencies.
• Assists in the mentoring and training of new staff.
• Assumes full responsibility for self-development and career progression; proactively seek and participate in ongoing training sessions (formal and informal).
• Comprehensively assembles and enters patient information into the appropriate delivery system to initiate the EAP, Care and Utilization management programs.
• Demonstrates flexibility in areas such as job duties and schedule in order to aid in better serving members and help organization achieve its business and operational goals.
• Educates providers on how to submit claims and when / where to submit a treatment plan.
• Identifies and responds to Crisis calls and continues assistance with the Clinician until the call has been resolved.
• Informs providers and members on appeal process.
• Leads or participates in activities as requested that help improve Care Center performance, excellence and culture.
• Links or makes routine referrals and triage decisions not requiring clinical judgment.
• Performs necessary follow-up tasks to ensure member or provider needs are completely met.
• Provides information regarding in-network and out-of-network reimbursement rates and states multiple networks to providers.
• Refers callers requesting provider information to Provider Services regarding professional provider selection criteria and application process.
• Refers patients / EAP clients to the Care Management team for a provider, EAP affiliate, or Facility.
• Responsible for updating self on ever changing information to ensure accuracy when dealing with members and providers.
• Support team members and participate in team activities to help build a high-performance team.
• Thoroughly documents customers' comments / information and forwards required information to the appropriate staff.

Minimum Qualifications :

Additional Qualifications :

Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sex (including pregnancy), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law. We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law. Prime Therapeutics LLC is a Tobacco-Free Workplace employer.