Department:

13581 Value Enablement Services - Clinical Insights & Operations: Customer Solution Center & Concierge

Status:

Full time

Benefits Eligible:

Yes

Hours Per Week:

40

Schedule Details/Additional Information:

Monday to Friday 8:00am to 4:30pm

Pay Range

$24.10 - $36.15

Major Responsibilities: Eligibility, Benefits, & General Duties 1)Obtain & validate a complete understanding of associate concern(s) and/or inquiry, assessing the concern/inquiry to determine the appropriate response/resource, and triaging to the appropriate resource when applicable 2)When necessary, act as a liaison for the associate between multiple departments within Advocate, the appropriate insurance company, providers rendering service, or outside entities contracted as part of the EPO plan of benefits to ensure associate questions and concerns are appropriately triaged and/or responded to resolve outstanding issues 3)Deescalate callers that are distraught or upset due to real or perceived difficulties they have encountered. Make logical and accurate decisions often while facing stressful situations (applies to all categories) 4)Follow appropriate scripts and procedures. Frame and communicate outcomes of investigations in an optimal manner leaving callers with a position view of Advocate, even if resolution is not what they originally anticipated (applies to all categories) 5)Retrieve and respond to all voicemail messages within one business day 6)General medical terminology and understanding of the plan as well as all resource tools available to associates, provider network, restrictions, and processes specific to the EPO plan 7)Researching eligibility disputes; contacting Managed Care Organization, HR Direct, ADP, etc. to resolve outstanding concerns on behalf of the Advocate associate 8)Complete documentation of telephone inquiries utilizing the established call documentation database 9)Manage follow-up timely for any open/unresolved escalations Claim, Referral, & Waiver Issues 1)Responsible for review and application of individual, HMO contract benefits provisions, and for identifying and reporting any discrepancies as it related to claim adjudication, referral/waiver entry, and/or Advocate network access. 2)Apply special rules and/or guidelines as determined by the benefit plan, network access, referral, and/or waiver process as part of the communication with the Advocate associate and/or their dependents so they are fully aware of impact to benefit. 3)Assures that denied claims and referral/waivers are rectified in timely manner as appropriate. 4)Intervenes to diffuse member call/accounts in collection contacting agencies to make adjustments or hold while issue is researched. Customer Care and Service Excellence 1)Prompt and accurate handling of routine and non-routine customer service inquiries. 2)Take ownership for each contact and provide consistent, high quality customer service that matches the marketing image and brand of Advocate Health Care 3)Requires professional communication, up to and including, framing outcomes of investigation in an optimal manner leaving the associate with a positive view of Advocate regardless of the outcome 4)Using a translation service when language other than English is preferred means of communication as necessary. Quality 1)Conducts calls in accordance with all metrics and measure used to evaluate call quality & productivity measures 2)Responsible for self-assessment of customer inquiries and escalation of high reliability events 3)Call monitoring will be reviewed on a monthly basis and recommendations for self-improvement will be discussed during coaching sessions Customer & Provider Education and Assistance 1)Facilitates changes to ensure the accuracy of all operation issues related to providers, i.e., dictionary updates, provider listings, referral processing, claims payment and fee schedules. 2)Reviews causes for billing errors and assists providers in making appropriate corrections. Reports potential issues with Ingenix and IDX. 3)Reviews risk grids and educates providers, MCO representatives and others regarding payment responsibilities. Reports potential system errors via CCIRP. 4)Assist members and physician office staff in checking referral status in computer. Researches referrals for members. 5)Reviews, obtains and verifies accurate information on dictionary vendor request forms for loading or changing of new/existing contracted providers. 6)Follow-through and responding to benefit plan concerns; educating caller on interpretation of the benefit question. Escalate any benefit discrepancies identified during the course of investigation for resolution. 7)Responsible for initiating calls to MCO, or any other entity tied to the benefits for Advocate associates Education/Experience Required: 4-5 years of managed care or business experience in healthcare field specific to interpreting benefit plans 1-2 years of customer service experience College degree or equivalent work experience Demonstrated ability to excel in this role Medical terminology Knowledge, Skills & Abilities Required: Excellent communication skills Ability to work independently Knowledge of PC, Microsoft Office, and database environment Excellent problem solving skills Ability to read and interpret standard plan language, and effectively communicate back to inquiry Ability to assess situations to optimize call center performance N/A Physical Requirements and Working Conditions: Ability to sit for long periods of time Ability to work on computer for long periods of time Proven history of punctuality and ability to adhere to a structured work schedule None This job description indicates the general nature and level of work expected of the incumbent. It is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities required of the incumbent. Incumbent may be required to perform other related duties.

Our Commitment to You:

Advocate Health offers a comprehensive suite of Total Rewards: benefits and well-being programs, competitive compensation, generous retirement offerings, programs that invest in your career development and so much more – so you can live fully at and away from work, including:

Compensation

Base compensation listed within the listed pay range based on factors such as qualifications, skills, relevant experience, and/or trainingPremium pay such as shift, on call, and more based on a teammate's jobIncentive pay for select positionsOpportunity for annual increases based on performance

Benefits and more

Paid Time Off programsHealth and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term DisabilityFlexible Spending Accounts for eligible health care and dependent care expensesFamily benefits such as adoption assistance and paid parental leaveDefined contribution retirement plans with employer match and other financial wellness programsEducational Assistance Program

About Advocate Health 

Advocate Health is the third-largest nonprofit, integrated health system in the United States, created from the combination of Advocate Aurora Health and Atrium Health. Providing care under the names Advocate Health Care in Illinois; Atrium Health in the Carolinas, Georgia and Alabama; and Aurora Health Care in Wisconsin, Advocate Health is a national leader in clinical innovation, health outcomes, consumer experience and value-based care. Headquartered in Charlotte, North Carolina, Advocate Health services nearly 6 million patients and is engaged in hundreds of clinical trials and research studies, with Wake Forest University School of Medicine serving as the academic core of the enterprise. It is nationally recognized for its expertise in cardiology, neurosciences, oncology, pediatrics and rehabilitation, as well as organ transplants, burn treatments and specialized musculoskeletal programs. Advocate Health employs 155,000 teammates across 69 hospitals and over 1,000 care locations, and offers one of the nation’s largest graduate medical education programs with over 2,000 residents and fellows across more than 200 programs. Committed to providing equitable care for all, Advocate Health provides more than $6 billion in annual community benefits.