Customer Service Representative I

Santa Clara Family Health Plan; San Jose (CA); On-site; USD 56,000 - 81,000; Full time

Job summary

Santa Clara Family Health Plan is seeking a Customer Service Representative I to handle inbound and outbound calls, supporting the Customer Service Department while ensuring compliance with Medicare and Medi-Cal regulatory requirements and achieving call center service level objectives.

You will assist members and providers with questions about eligibility, benefits and access to services, document interactions, escalate issues when needed, and participate in ongoing training to maintain high

Qualifications

• High School Diploma or GED required.
• Minimum one year of experience in Customer Service or Call Center.
• Bilingual skills in Spanish, Vietnamese, Chinese, or Tagalog preferred.
• Proficiency with Outlook, Word, and Excel.

Responsibilities

• Serve as primary contact for members and providers via inbound/outbound calls.
• Explain plan services and benefits; resolve inquiries.
• Document contacts and follow-ups per guidelines.
• Triages requests to other departments as needed.
• Handle member grievances, appeals, and billing issues.
• Participate in daily/weekly/monthly meetings and training.
• Educate members on eligibility and access to services.
• Maintain confidentiality and comply with policies.

Skills

Bilingual (Spanish, Vietnamese,Chinese

Communication skills

Keyboarding

Confidentiality

Office software

Education

High School Diploma or GED

Tools

Outlook

Word

Excel

Job description

Salary Range: $55,958 - $81,139
The expected pay range is based on many factors, such as experience, education, and the market. The range is subject to change.

FLSA Status: Non-Exempt
Department: Customer Service
Reports To: Supervisor, Customer Service

Employee Unit: Employees in this classification are represented by Service Employees International Union (SEIU) Local No. 521

GENERAL DESCRIPTION OF POSITION

The Customer Service Representative I answers inbound calls and makes outbound calls to support Customer Service Department operations in a manner that maintains compliance with Medicare and Medi-Cal regulatory requirements and achieves Call Center service-level objectives.

ESSENTIAL DUTIES AND RESPONSIBILITIES

To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below.

1. Act as the primary point of contact and liaison for SCFHP members and providers contacting the plan regarding general inquiries, concerns or requests for information.
2. Develop a general understanding of all member facing materials, communications and interactions and be prepared to respond appropriately to follow up calls.
3. Answer inbound calls and/or place outbound calls in a high call volume environment and work directly with members and providers to accurately and completely answer inquiries involving SCFHP program services and benefits.
4. Follow established guidelines and resources to respond to member and provider inquiries and resolve concerns in an accurate, timely, professional, and culturally competent manner.
5. Intake, handle and coordinate member grievances, appeals and billing issues, escalating to the Grievance and Appeals department, when necessary.
6. Educate members and providers on eligibility, and medical and pharmacy benefits and how to access services in a manner that achieves excellent service standards and maintains high customer satisfaction.
7. Use listening skills and judgment to appropriately categorize and accurately document all contacts and follow-up actions regarding member and provider communications and activities in accordance with established guidelines.
8. Appropriately handle member and provider requests through alternative channels such as e-mail, voicemail, fax, walk-in, etc. in accordance with established procedures.
9. Triage member and provider requests or inquiries for other departments.
10. Conduct member surveys as assigned in accordance with established guidelines.
11. Attend and actively participate in daily, weekly, and monthly departmental meetings, in-services, training and coaching sessions.
12. Identify member/provider issues and trends and report relevant information to management.
13. Perform other related duties as required or assigned.

REQUIREMENTS - Required (R) Desired (D)

The requirements listed below are representative of the knowledge, skill, and/or ability required or desired.

1. High School Diploma or GED. (R)
2. Minimum one year of experience in Customer Service or Call Center role, preferably within a Health Care, Public Assistance or Human Services programs. (R)
3. Prior experience with managed care plans, Medi-Cal and Medicare programs, and working with underserved populations. (D)
4. Ability to meet Key Performance Indicators by participating in and achieving the standards of the Customer Service Call Center Quality Program. (R)
5. Spanish, Vietnamese, Chinese, or Tagalog language bi-lingual skills. (D)
6. Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications, such as Outlook, Word and Excel. (R)
7. Ability to use a keyboard with moderate speed and a high level of accuracy. (R)
8. Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP Plan members and providers over the telephone, in person or in writing. (R)
9. Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R)
10. Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R)
11. Ability to maintain confidentiality. (R)
12. Ability to comply with all SCFHP policies and procedures. (R)
13. Ability to perform the job safely with respect to others, to property, and to individual safety. (R)

WORKING CONDITIONS

Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications.

PHYSICAL REQUIREMENTS

Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation:

1. Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R)
2. Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R)
3. Visual Requirements: ability to read information in printed materials and on a computer screen; perform close‑up work; clarity of vision is required at 20 inches or less; (R)
4. Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note‑taking); ability to operate a computer keyboard and other office equipment (R)
5. Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R)
6. Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R)

ENVIRONMENTAL CONDITIONS

General office conditions. May be exposed to moderate noise levels.

EOE