As a Customer Care Representative (CCR), you are in charge of upholding our mission of providing service worthy of our family and friends. Our priority is for our members to experience the upmost of care and compassion by conveying empathy and resolving all issues and helping them get back to enjoying their lives as quickly and effortlessly as possible. You are empowered to provide members with peace of mind that their current issue is resolved and that none are on the horizon.
Successful CCRs deliver an effortless customer experience by:
Taking the lead - our CCRs take ownership of members' issues, relieving members' stress while guiding them to a quick and easy resolution.
Identifying future problems - not only do our CCRs solve the current member concern but they actively identify and solve any lurking complications the member may encounter after their first interaction.
Sharing insights with peers and management - our positive team culture relies on open communication to continuously improve how our work gets done.
Having fun! - our work is important, but we don't take ourselves too seriously. We love helping others and have a fun community dedicated to doing so!
Who We're Looking For:
In the Customer Care team, we value our employees as much as our members. This job isn't for the faint of heart. No two members, problems, or resolution journeys are the same. Sometimes you won't know the right answer, but we're looking for someone who is always up for the challenge.
Our team members are the kind of people who create a plan and take charge in situations where others feel lost. If you excel at figuring out logic puzzles, welcome challenges, and have a passion around helping others in what could be their most vulnerable moment, then we bet you have the right stuff!
We're looking for people best described as:
A proactive, solution-oriented decision maker
A planner, multi-tasker, and expert problem solver
Outspoken, with a "can-do" attitude and infectious positivity
A compassionate individual who can convey empathy
Essential Responsibilities include, but are not limited to:
Resolves incoming calls concerning members eligibility, benefits, provider information, monthly premium billing, clinical and pharmacy needs.
Composes routine and non-routine correspondence to answer benefits/provider inquiries in writing.
Coordinates membership changes such as member's primary care physician.
Performs inventory reduction, routine to mid-level, (i.e. member inquiries, may initiate claim adjustments, responds to emails, etc.)
Reviews and analyzes member claims for accuracy as well as member education on how benefits are applied.
Participate in quality and efficiency workgroups to continuously improve quality member/customer satisfaction as requested.
Proactively analyze available programs, determine program eligibility and connect member to appropriate BSC vendors, Health Advocates, Social Workers, Pharmacy Techs, and Pharmacists. Verify the member is included in or targeted for any outreach or care gap programs and connect members to programs or services when appropriate. Engage members with their wellness plan options.
Enhanced knowledge of medical terminology.
Comprehensive resolution of pharmacy calls concerning benefit coverage, co-pays, formulary coverage, vacation overrides, and utilization management requirements.
Provide prescription related benefit coverage (e.g. explanation of coverage or benefit summary related): Provide prescription co-pays. Provide prescription formulary coverage information and utilization management requirements using web posted printed formulary. Provide a brief description of coverage denial reason and alternatives as listed in the printed formulary. Perform prescription claim overrides.
Provide deductible and max out of pocket information.
Provide status of a prior authorization requests.
Assist members may when and how to appeal a coverage decision.
Other duties as assigned.
Knowledge and Experience
Requires basic job knowledge of systems and procedures obtained through prior work experience or education.
Typically, requires minimum of 3 years of experience.
May require vocational or technical education in addition to prior work experience.
About Company: At Blue Shield of California we are parents, leader, students, visionaries, heroes, and providers. Everyday we come together striving to fulfill our mission, to ensure all Californians have access to high-quality health care at a sustainably affordable price. For more than 80 years, Blue Shield of California has been dedicated to transforming health care by making it more accessible, cost-effective, and customer-centric. We are a not-for-profit, independent member of the Blue Cross Blue Shield Association with 6,800 employees, more than $20 billion in annual revenue and 4.3 million members. The company has contributed more than $500 million to Blue Shield of California Foundation since 2002 to have a positive impact on California communities. Blue Shield of California is headquartered in Oakland, California with 18 additional locations including Sacramento, Los Angeles, and San Diego. We're excited to share Blue Shield of California has received awards and recognition for - LGBT diversity, quality improvement, most influential women in corporate America, Bay Area's top companies in volunteering & giving, and one of the world's most ethical companies. Here at Blue Shield of California, we're striving to make a positive change across our industry and the communities we live in - Join us!
EEO Footer: External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.