Customer Service Rep III
Shift: 8:00am to 6:00pm
(Shift Bidding process based on seniority)
Analyze, evaluate, resolve, respond and adjudicate to resolution customer/provider inquires received via telephone, correspondence or in person involving a variety of claim/benefit issues under various product lines. In addition to providing a full range of customer service, the incumbent will assist other representatives and handle unusual or complex inquiries, including irate calls and those inquiries that may have impact on the retention of a group contact. May make visits to customer location, adjudicate special claims/inquiries and expedite claims/inquiries via special handling. Handles more complex and/or sensitive inquiries which demand a higher level of knowledge of skills, including all of the following:
Inquiries originating from group decision makers, group personnel office marketing representatives, health care affairs representatives, state/federal government offices, and BCBSM management.
Appealed inquiries, disputed cases, and inquiries from groups in jeopardy.
Inquiries that involve deviations from normal corporate processing procedures
Conducts internal and external extensive research or special studies necessary to handle disputed inquiries from subscribers, beneficiaries, accounts, providers, unions or management referrals. Obtains all needed external data on behalf of the subscriber.
Analyzes and services various product lines in the area (i.e., Administrative, Facility, Professional, Special, Programs, Medicare/Complimentary). Provides servicing responses predominately by written correspondence or where appropriate by telephone.
Initiates status reports to the inquirer when delays occur in responding to an inquiry as required.
Follows department/corporate reporting requirements.
Organizes work to meet National/corporate/Department production and quality standards.
Reroutes misdirected inquiries.
Evaluates and price/adjudicates claims/inquires requiring special handling.
Interacts with others inside and outside the organization to resolve inquiry/claim related problems.
Determines the dollar amount of additional payments and directs the issuance of a check,
Influences customers to accept systems changes to accommodate corrective measures for group subscribers and providers.
Identifies/initiates appropriate systems changes to accommodate corrective measures for group subscribers and providers.
Assists other representatives and handles unusual or complex inquires, including irate calls as well as those inquires that may have implications for retention of a group/contract, or provider.
Perform other related duties as assigned.
High School Graduate or GED equivalent and one (1) year as a Customer Service Representative II Level position required.
Two (2) years of related experience in areas such as public/customer service, sales, claims processing or membership enrollment and one (1) year of public contact experience in positions such as teaching, social service work, bank teller, medical assistant or office assistant.
Four (4) years of total related experience.
Working knowledge of BCBSM policies, practices and procedures related to various lines of business including Medicare/Complimentary.
Comprehensive knowledge of History Files, Subscriber Files, and Special Program Files.
Medical terminology knowledge.
Demonstrated knowledge of policies, practices and procedures related to billing or contract coverage or changes, or rating and eligibility requirements or claims processing.
Demonstrated ability to analyze data and resolve problems related to inquiry and claims processing.
Spanish speaking ability may be required in the Holland office.
Demonstrated command of all skills necessary for verbal and written communications with subscribers/beneficiaries/accounts or providers, in a clear, concise and tactful manner.
Other related skills and/or abilities may be required to perform this job.
All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, gender identity, protected veteran status or status as an individual with a disability.
Equal Opportunity Employer - minorities/females/veterans/individuals with disabilities/sexual orientation/gender identity
Please see job description for required skills.