CUSTOMER SERVICE REPRESENTATIVE

CUSTOMER SERVICE REPRESENTATIVE - BILINGUAL SPANISH

Customer Service Representative - BILINGUAL SPANISH - 12000320 Description Health Net, Inc. is a publicly traded managed care organization that delivers managed health care services through health plans and government-sponsored managed care plans. Its mission is to help people be healthy, secure and comfortable. The company provides health benefits to approximately 6.0 million individuals across the country through group, individual, Medicare (including the Medicare prescription drug benefit commonly referred to as "Part D"), Medicaid, Department of Defense, including TRICARE, and Veterans Affairs programs. Health Net's behavioral health services subsidiary, Managed Health Network, Inc., provides behavioral health, substance abuse and employee assistance programs to approximately 5.4 million individuals, including Health Net's own health plan members. The company's subsidiaries also offer managed health care products related to prescription drugs, and offer managed health care product coordination for multi-region employers and administrative services for medical groups and self-funded benefits programs. For more information on Health Net, Inc., please visit the company's website at www.healthnet.com . JOB SUMMARY: Under general supervision the Customer Service Representative II handles customer inquiries including but not limited to claims and benefit interpretation. Services prospective members, enrolled members, providers, employers, vendors, and other Health Net customers. This position is responsible for resolving all aspects of customer inquiries and complaints, for providing accurate and timely responses, and entering accurate information into the customer database. May provide assistance or train less experienced associates on the handling of complicated issues. ESSENTIAL DUTIES AND RESPONSIBILITIES: Handles general inbound ACD calls, correspondence, and lobby visits related to all aspects of service. Effectively communicates, in writing and verbally, Health Net policies, procedures, and applicable benefits to members and/or providers who have misinterpreted, were unaware of, or are questioning a Health Net policy or decision. May provide assistance or train less experienced associates on the handling of complicated issues. Must meet departmental standards for quality, productivity and teamwork. Communicates accurate information to customer questions and requests, by phone and/or in writing, in a courteous and professional manner. Investigates customers problems as indicated. Initiates appropriate action to ensure timely resolution, including outbound call resolution when necessary. Develops and maintains a comprehensive knowledge of all Health Net policies, procedures, products and services including the departmental processes of Medical Management, Network Management, Sales and Marketing and Government Programs. Identifies, analyzes and performs any of the following: Member/Provider eligibility and benefit questions and research Research, interpretation, and adjudication of complex/unique claims, including all aspects of COB, NF, Worker's compensation and claim recovery All correspondence including internet, emergency room appeals, member and employer questionnaires, enrollment applications and Authorization Services forms Facilitates filing of appeals and grievances Plans (including all Non-Standard Plans, ASO, and Government Programs) Enrollment and Eligibility Benefit Product comparisons, Exclusions, Limitations, and Product nuances Interpret Health Net remittance advices and member EOB's Performs data input in a highly accurate and timely fashion for all customer contacts, according to the customer information database system parameters. Assures documentation is complete, so department is able to monitor physician compliance, and analyzes, develops and/or changes, product, benefit and plan designs. Makes recommendations on contract language for easier customer interpretation. May provide recommendations for quality and productivity improvements to enhance service to all our customers. Participates in various training and information functions available to the Health Plan Operations staff members to enhance skills, improve performance, and contribute to the ongoing development and achievement of departmental goals. Qualifications REQUIREMENTS: Education: High School Diploma Certification/License: Experience: One year experience as a CSR I, or previous experience in HMO, insurance carrier or Third Party Administrator preferred Knowledge, Skills Abilities: Fluency in English and a second language, Spanish Completed training, and demonstrated proficiency in escalated call handling and resolution Demonstrated proficiency in Health Net's call center environment Demonstrated ability to work independently and as a member of a team Ability to mentor and train others Computer skills and familiarity with Window applications, with typing ability of 30 wpm required Ability to interact professionally with both internal and external contacts Able to work flexible hours, including weekends and evenings, as department or training needs dictate and at the discretion of management Strong written, oral and interpersonal communication skills Ability and desire to work in a fast paced environment is required OR Any combination of academic education, professional training or work experience, which demonstrates the ability to perform the duties of the position. Health Net, Inc. supports a drug-free work environment and requires pre-employment background and drug screening. Health Net and its subsidiaries are an Equal opportunity/Affirmative Action Employer M/F/V/D. Job - Provider Services Primary Location - California-Woodland Hills Organization - Health Net of California, Inc. - 4001 Schedule - Full-time Job Type - Regular Shift - Day Job Overtime Status - Non-exempt