Bilingual Customer Service Representative- Provider Assistance

Job Description

As a Third-Party Administrator for dozens of Healthcare Insurance companies located overseas, the Customer Service Representative is responsible for handling inbound requests received via phone and email for “Expat”, “Destination” and “Travel” patients whose medical services will take place either in the United States or the rest of the world. Besides providing coverage details to medical Providers/insured Members, coordinating cashless appointments worldwide, and providing bill status information to Providers, the CSR will work closely with the Case Management department on services that require authorization, which include identifying services that must be pre-certified and initiating the pre-authorization process. Last but not least, the CSR will be working with Account Management for any bill-related matters that need to be escalated.

Main daily responsibilities, but not limited to:

1. Direct communications with Members, Providers, and Corporate Clients via phone, email, and any type of communication.
2. Register Policies in the system with proper eligibility, add Members/dependents, and create appropriate tasks that will trigger proper workflow.
3. Documentation of all calls or communications in the Members record (when applicable).
4. Confirmation of Benefits and Eligibility information to members and providers.
5. Identify medical services that require an authorization from the Corporate Client and take appropriate actions (initiate authorization, provide status on existing ones, and escalate any issues to Case Management).
6. Coordination of medical services in/outside the USA, which, in most cases, includes locating and contacting several Providers who have the availability and suit the Members' preferences and accept our Guarantee of Payment for a cashless experience.
7. Ensure that Providers send claims to the proper address for processing and/or payment and that only the correct amounts are collected from the patient (deductible, co-payments, etc.).
8. Provide referrals to in-network Providers to all Members, Corporate Clients, and sometimes other Providers, confirming the participation of a specific Provider in the network.
9. Steer callers to in-network facilities/providers to generate higher revenue.
10. Provide claims information like status, process date, detailed payment amount, check number, discounts taken, etc. to Members, Corporate Clients, and Providers by making the necessary contacts.
11. Assist in resolving any billing issues by contacting the appropriate department and/or parties involved.
12. Identify balance billing by analyzing claim and payment information available.
13. Identify potential problems and take prompt corrective actions to avoid escalated issues that require supervisory intervention.
14. Keep Account Managers informed of any delicate issue that may require their attention to avoid or resolve an existing problem.
15. Calm irate Members and Providers and reassure them that their problems and concerns will be dealt with effectively and timely.
16. Apply knowledge, experience, common sense, and critical thinking to all issues being dealt with. Multitask and prioritize.
17. Make decisions on when a specific issue needs to be brought to the attention of the supervisor/manager.
18. Respond and address new business concerns from existing and potential customers.
19. Log and record all types of communications for patient files.
20. Respond to general queries from members (policy procedures, reimbursements, etc.). Redirect callers when necessary.
21. Follow up until completion on all issues that are not resolved on the initial contact, keeping parties updated on steps and actions taken.
22. Service the maximum amount of callers in the quickest and most efficient way without sacrificing the quality of the service.

Requirements:

1. Bilingual (English & Spanish).
2. Must be detail-oriented and organized.
3. Must possess critical thinking skills as well as the ability to manage time efficiently.
4. Must be able to gather the information necessary to assist customers.
5. Always be sharp and alert.
6. Needs to communicate well with co-workers (verbal and written).
7. Knowledge of phone manners, etiquette, and protocols.
8. Professional phone etiquette and written skills.
9. Ability to adapt to changes.
10. Able to understand, interpret, and explain policies and procedures as well as knowledge of commonly used concepts, practices, and procedures in the field.
11. Ability to deal with irate customers and complaints while maintaining composure and control of the situation.
12. Knowledge of Microsoft Office.
13. Ability to learn from past experiences.