Customer Service Representative

Dection Staffing Services

Position Responsibilities:

  • Addresses member inquiries, questions and concerns in all areas including enrollment, claims, benefit interpretation, and referrals/authorizations for medical care.
  • Verify member eligibility, claim and authorization status for providers.
  • Responsible for thorough follow-up and completion of all member, and provider inquires or requests
  • Responsible for accurate, complete and correct documentation into Facets regarding all issues, and/or inquires, complaints and grievances.
  • Function efficiently and productively in a high-volume telephone call center.
  • Maintain departmental productivity and quality standards.
  • Provide follow-up assistance as needed.
  • Route escalated calls to the appropriate Member Liaison, Supervisor or Call Center Manager
  • Refer issues to health networks and/or make recommendations for further contacts within CalOptima.
  • If designated, responsible for processing all member transportation request within 1 business day of receipt and coordinating all aspects of the process with clinic, provider and member as appropriate or necessary
  • Adhere to company and departmental policies and procedures.
  • • Assists Members with Company’s Member Web Portal registration and technical support. Other duties or projects as assigned by management.

Possess the Ability To:

  • Establish and maintain effective interpersonal relationships with members, coworkers and the public.
  • Function efficiently and productively in a high-volume telephone call center.
  • Effectively communicate both in writing and verbally.
  • Learn procedures and regulations governing member eligibility and the terminology and documents used while remaining knowledgeable of CalOptima/Medi-Cal benefits and procedures.
  • Understand and follow oral and written directions.
  • Hear and speak well enough to converse on the telephone and in person.
  • Perform work requiring repetitive use of hands, arms or shoulders (e.g. keyboarding, typing, etc.).
  • Effectively utilize computer and appropriate software and interact as needed with CalOptima Information Systems.


Experience & Education:

  • High school diploma or equivalent required.
  • 6 months call center experience with high call volumes or customer service experience analyzing and solving customer problems required. HMO, Medi-Cal/Medicaid and health services experience preferred.
  • Bilingual in English and in one of Company’s defined threshold language is required.

Knowledge of:

  • Principles and practices of managed health care, health care systems, and medical terminology.
  • Principles and techniques for handling customer service issues.
  • Personal computers, keyboarding, and appropriate software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.
  • Understanding of the Company program.
  • Customer service principles and practices.

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