Customer Solutions Representative

Resolves a variety of difficult issues for providers and members. To provide efficient, effective quality customer service to members, physicians, vendors, employer groups, managed care organizations and contracted Physician Hospitals Organizations and Advocate Health Centers. Addresses previously processed claims and reprocesses as needed Educates providers, billing personnel, members and MCO representative regarding plan provisions, risk issues, billing processes and errors, contract terms, eligibility issues and referral guidelines. Resolves internal and external issues for the caller.

Major Responsibilities:

• Resolution of complex requests from APP physician offices or patients, including those related to membership or incentive elements. Conducts calls in accordance with all metrics and measures used to evaluate call quality and productivity, as established by Help Desk responsible for initiating calls to HMOs, primary care physicians, PHO, or members to resolve any outstanding issues. Intervenes to diffuse member calls/accounts in collection. Contacts agencies to make adjustments and payment arrangements from APP or MCO when applicable.
• Frame and communicate outcomes of investigation in an optimal manner leaving callers with a positive view of Advocate even if resolution is not what they originally anticipated. Service will be provided to internal and external customers for AHPO and AHC by having a rapid response to inquiries, efficient routing of requests to other AHPO departments when needed, and responding to callers in a customer friendly, focused environment.
• Using excellent interpersonal skills deescalate callers that are distraught or upset due to real or perceived difficulties they have encountered. Make logical and accurate decisions often while facing stressful situations.
• Assures that denied claims and referrals are rectified in a timely manner. Adjust and make final payment or denial determination for previously processed claims per AHPO guidelines. Identify claims that require coordination of benefits (COB) and apply claim adjudication rules per AHPO guidelines. Responsible for initiating calls to HMOs, primary care physician, PHO or member to resolve any outstanding issues. Assists in retrieving and responding to all voicemail messages within one (1) business day, and in incoming calls.
• Research eligibility disputes: contacts managed care organizations, employers, and tests updates to Epic Tapestry Claims System and works closely with the Eligibility Department if retro capitation situations occur. Reviews causes for billing errors and assists providers in making appropriate corrections. Reports potential issues with Epic Care Link and Epic Tapestry Claims System.
• Assist members and physician office staff in checking referral status in computer. Research referrals for members. Reviews, obtains, and verifies accurate information on dictionary vendor request forms for loading or changing of new/existing contracted providers. Responds to benefit plan concerns and educates callers on interpretation of the benefits. Reports copay and other benefit loading errors and delays when they are identified.
• Reviews risk grids and educates providers, MCO representatives and others regarding payment responsibilities. Reports potential system errors Service Now.
• Documents all complaints/grievances and refers to appropriate department when required (QI, systems, UM, Provider Relations, Service Enhancements, etc.). Acts as a liaison between various AHPO departments to identify system related capitation, referral and eligibility problems and works with various departments to ensure proper resolution
• Assists members in primary care selection and primary care changes. Documents and updates Epic Tapestry System Complete documentation of telephone inquiries utilizing the Customer Service Module. Facilitates changes to ensure the accuracy of all operation issues related to providers, i.e., dictionary updates, provider listings, referral processing, claims payment and fee schedules.
• Responsible for review and application of individual; contract benefit provisions and for identifying and reporting any discrepancies. Apply special rules and/or guidelines as determined by the medical director or senior management.
• Compile audit data. Assess output of data and complete preliminary summary of conclusions and is some cases recommendations. Graph data in MS Excel, enter data in MS Access as needed, Assist with simpler auditing functions. Assist with follow-up on contract scrubbing and other future improvement projects. Make sure projects are remaining on time to reach target dates for completion.

License/Registration/Certification: N/A

Education: High School Diploma

Experience: 3 Years of managed care or healthcare environment in call center, accounts receivables or claims.

KNOWLEDGE, SKILLS AND ABILITIES

• Demonstrated experience and skill in utilizing PC applications & Microsoft Office products.
• Ability to work independently & prioritize assignments.
• Ability to problem solve & diffuse difficult callers, maintaining professionalism at all times.
• Effective Organizational and Communication Skills
• Ability to read and interpret standard contracts. In addition, able to interpret contract language to external customers.
• Knowledge of evolving health care delivery environment
• Demonstrate self-directed results-oriented, creative approach to projects
• Ability to succeed in changing environment and handle multiple responsibilities
• Demonstrated ability to problem solve and analyze procedure and process changes
• High aptitude for information decision support systems
• Experience in process implementation and facilitation

Physical Requirements and Working Conditions:

Ability to adjust to Flexible hours. This is a remote position. Current shift assignment is Monday-Thursday 8:30-5pm and Friday 8-4:30pm.

This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.