Customer Care Representative – Day Shift

This is a fully remote position, open to applicants in California.

📋 Description

• Engage promptly and directly with Plan members, prospective members, providers, employer groups, brokers, internal departments, and external agencies.

• Provide detailed information regarding Plan products, premiums, benefits, policies, and procedures.

• Investigate and resolve customer issues accurately.

• Document calls along with member concerns, complaints, and appeals.

• Verify eligibility, enrollment, benefits, claims, authorizations, premiums, and PCP assignments utilizing IDX, MedAccess, Salesforce, and related systems.

• Add and update member information, and generate or retrieve member documentation.

• Address inquiries concerning benefits, referrals, PCP changes, ID cards, premium and subsidy amounts, COBRA, and Cal-COBRA procedures.

• Support members in understanding coverage, enrollment materials, provider-network services, as well as premium and billing questions.

• Process ACH and credit-card payments over the phone.

• Collaborate with internal departments, healthcare providers, vendors, employers, brokers, and other customers.

• Participate in special projects, work groups, proposals, audits, and provide departmental backup support.

• Identify and suggest solutions to operational challenges.

• Ensure compliance with DMHC, CMS, NCQA, regulatory, and accreditation standards.

• Work on designated projects including member orientation, billing reminders, member education, claims investigation, pharmacy authorizations, appeals, and reimbursement requests.

⛳️ Requirements

• High school diploma or equivalent qualification.

• A minimum of six months of experience in a Customer Call Center Representative role.

• Basic computer and writing capabilities.

• Proven knowledge of Plan benefits, policies, and procedures.

• Familiarity with health maintenance organizations, performance management, and customer satisfaction assessment and delivery.

• Mature judgment and sound decision-making skills.

• Excellent interpersonal abilities.

• Capability to engage effectively in Customer Care activities.

• Bilingual skills are preferred but not mandatory.

• Medical office certification, including knowledge of medical terminology, is preferred.

• Must adhere to departmental scorecard, behavior, attendance, and knowledge assessment standards.

🏝️ Benefits

• Comprehensive health and wellness programs.

• Opportunities for professional development and career advancement.

• Competitive compensation packages.

• Supportive and inclusive work environment.