JOB SUMMARY The Customer Advocate 3 communicates to Members and Providers the policies, procedures and services of the Health Plan (Plan), and handles any complaints concerning the Plan. This position works on behalf of Members to resolve any issues and concerns or participate in appeal hearings. This position will also assist management by servicing as a team leader and/or subject matter expert, providing training and assistance to staff.
ESSENTIAL FUNCTIONS OF THE ROLE Communicates to Members and Providers policies, procedures and services of the Plan to ensure complete understanding of the Plan. Adheres to established call handling goals and call abandonment rate policies. Maintains an average score of ninety-two percent (92%) or above for monthly quality audits on two percent (2%) of calls audited. Observes department policy of average hold time below one (1) minute. Supports and meets scheduled adherence goals based on department policies. Practices advocacy behaviors with every customer interaction and promotes service excellence.
Serves as a primary contact for benefits, claims status, claims adjustments and drug inquires for all product lines including third party administrators (TPAs) and other products and provides offline support. Completes documentation of transactions performed for Members and Providers.
Acts as subject matter expert (SME) for claims and enrollments, TPAs, ICSW and all other products. Assists Members with access to the Plan system, helps Members choose an appropriate physician, and assists with appointments.
Acts as liaison between Members and Providers billing offices, with follow through to resolve issues. Verifies demographic information on all inquiries and updates as appropriate. Assists members with concerns and actively works toward a resolution before the concern escalates to a complaint. Documents member complaints based on regulatory requirements of the Centers for Medicaid and Medicare Services (CMS) and the Texas Department of Insurance (TDI).
Accesses appropriate sources (BENS, Amisys, AboveHealth etc.) to obtain benefit information requested by Members and Providers. Accurately documents phone long records for each inquiry with appropriate messaging based on department standards.
Participates in projects, representing the goals of the department, the Plan and the organization.
Actively engaged in ensuring department metric are being met. May assists in the development and revision of department policies and procedures. Promotes and practices advocacy behaviors and service excellence with every customer interaction.
Participates in member appeal hearings and address any questions and or concerns of the Member. May serve as a Lead Advocate in scheduling of appeal hearings.
Assists in training, mentoring or providing guidance for new and existing Advocates.
Performs other position appropriate duties as required in a competent, professional and courteous manner.
KEY SUCCESS FACTORS Must be successful in completion of internal customer service competency testing.
Must possess excellent phone etiquette and uses effective communication skills (both verbal and written).
Must be able to multi-task.
Must be able to problem solve and act as an advocate for the customer.
Must be able to work perform repetitive task
Our competitive benefits package includes the following - Immediate eligibility for health and welfare benefits - 401(k) savings plan with dollar-for-dollar match up to 5% - Tuition Reimbursement - PTO accrual beginning Day 1 Note: Benefits may vary based upon position type and/or level
- EDUCATION - H.S. Diploma/GED Equivalent
- EXPERIENCE - 4 Years of Experience
Internal Number: 21005742rxv_31_1
About Baylor Scott & White Health
Baylor Scott & White Health (BSWH) is the largest not-for-profit health care system in Texas and one of the largest in the United States. With a commitment to and a track record of innovation, collaboration, integrity and compassion for the patient, BSWH stands to be one of the nation’s exemplary health care organizations. Our mission is to serve all people by providing personalized health and wellness through exemplary care, education and research as a Christian ministry of healing. Joining our team is not just accepting a job, it’s accepting a calling!