Representante de Servicio al Cliente - Resolucion al Cliente
Regular
Non-Exempt
GENERAL DESCRIPTION:
Handles transferred phone calls from insured individuals of the Classicare business line. Provides extended benefit guidance to clarify doubts for Classicare beneficiaries facing high complexity situations related to the beneficiary value programs services. Resolves service situations or needs, by channeling them through established operational processes, and service guidelines, and documents the provided service to ensure continuity of services offered by the company Call Center.
ESSENTIAL FUNCTIONS:
Handles inbound calls transferred from the Classicare Call Center originating from affiliates who voice concerns, uncertainties, or dissatisfaction related to high-complexity benefit situations, processes, coverage, beneficiary value programs, and over-the-counter (OTC) matters, among other issues. Provides comprehensive and detailed guidance on benefits to address concerns, alleviate doubts, and offer clarity to beneficiaries who exhibit or have exhibited heightened dissatisfaction with the service. Additionally, engages with individuals expressing a desire to cancel or disaffiliate their coverage, aiming to resolve issues and retain their satisfaction with the provided services.
Makes outgoing (Outbound) calls to ensure the closure of the service cycle for handled cases and makes modifications related to demographic information, if necessary.
Contacts existing beneficiaries showing trends of unfavorable responses in satisfaction surveys conducted by the plan coverage, aiming to ensure satisfaction with the service.
Conducts outbound calls for different established campaigns, according to quality standards, offering fast, courteous, and
efficient service to resolve issues arising during calls when necessary.
Works on received cases through the case referral tool, internal referrals from other departments, voicemail messages, fax, website, social media, and pharmacy coverage activations, according to established processes.
Works together with the other departments to ensure the dispatch of the beneficiary value programs, and over-thecounter (OTC) cards returned by mail.
Evaluate the service situation of each affiliate before contacting them, to identify which service situation to impact and establish the course of action to follow. Refers to support departments as applicable, following up until a response is obtained.
Keeps the customer informed of the status, notifies the result of the request to complete the service cycle, and documents all the actions performed in the Customer Relationship Management (CRM) tool to complete the service cycle.
Serves as the first level of support for the Commercial business line, handling cases received through the case referral tool (CRM).
Ensures work on the assigned case inventory, such as closing the assigned case, maintaining individual production equal
to or above the group average, in CRM cases, voicemails, faxes, and interpreter coordination, and promptly handles cases.
Generates transaction reports related to the beneficiary values program benefit through the established tool and administers returned beneficiary value program cards. Receives and reconciles mail received within established times, ensuring proper handling of the beneficiary value program cards.
Keep other departments informed of any information related to the beneficiary value program's benefit.
Receives, evaluates, and evaluates cases that may be referred to compliance, and if necessary, refers them for the corresponding process with detailed information and analysis worked on.
Ensures in the analog and digital TTY telephone system, that it answers before the third ring and provides correct information to the customer. Performs availability tests of TTY lines, keeps a record of these, and reports any situation that could impact the operation of the application and line availability.
Uses connection and disconnection states correctly in the ACD, ensuring availability to receive transferred calls; also
responsible for contacting the client when the transfer is unsuccessful.
Evaluate, resolve, and document through the call the situations presented by the insured.
Prepares coverage certifications and letters for services not covered, among others, as requested by the insured or provider.
Keeps the database of the applicable information system updated, regarding insured demographic information.
Processes card duplicates and other service requests, such as Primary Care Physician (PCP) change, and premium payment, among others, through applicable systems.
Refers to received complaints from insured parties to the corresponding unit, following the established protocol.
Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.
May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.
MINIMUM QUALIFICATIONS:
Education and Experience:
Sixty (60) college credits equivalent to two (2) years of study or an Associate's degree. At least one (1) year of experience in customer service-related work.
OR
Education and Experience:
High school diploma. At least two (2) years of experience in customer service-related work.
"Proven experience may be replaced by previously established requirements."
Certifications / Licenses:
N/A
Other:
Knowledge of medical billing is preferred. Availability to work rotating shifts, Saturdays, Sundays, and holidays.
Languages:
Spanish –
Intermediate (comprehensive, writing and verbal)
English –
Intermediate (comprehensive, writing and verbal)
"Somos un patrono con igualdad de oportunidad en el empleo y tomamos Acción Afirmativa para reclutar a Mujeres, Minorías, Veteranos Protegidos y Personas con Impedimento
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