Job Description

Role Purpose

Positions in this function are responsible to determine if prior authorization is required and can be decisioned, or if it requires additional clinical review. Individuals support clinicians by contacting health providers and/or members to verify authorization or referral, setup cases, and document findings. Positions in this function includes those responsible for initial triage of members, administrative intake of members and working with hospitals and the clinical team.

͏

Primary Responsibilities:
• This is a production role and you will have the responsibility to meet production, quality and regulatory expectations
• Ensure case is set up correctly and document required information 
• Review, research and determine if case can be decisioned or if it requires additional clinical review 
• Demonstrate proficiency and decision making by solving complex problems using available resources (documents, 
medical policy, standard operating procedure, etc.)
• As needed, make outbound calls to providers and/or members to obtain information regarding a case
• As needed, make outbound calls to providers to coordinate provider availability in treating members
• Other duties as assigned by manager and/or director

͏

• Deliver excellent customer service through effective diagnosis and troubleshooting of client queries
  • Provide product support and resolution to clients by performing a question diagnosis while guiding users through step-by-step solutions
  • Assist clients with navigating around product menus and facilitate better understanding of product features 
  • Troubleshoot all client queries in a user-friendly, courteous and professional manner
  • Maintain logs and records of all customer queries as per the standard procedures and guidelines
  • Accurately process and record all incoming call and email using the designated tracking software
  • Offer alternative solutions to clients (where appropriate) with the objective of retaining customers’ and clients’ business
  • Organize ideas and effectively communicate oral messages appropriate to listeners and situations
  • Follow up and make scheduled call backs to customers to record feedback and ensure compliance to contract /SLAs

͏

Build capability to ensure operational excellence and maintain superior customer service levels of the existing account/client
• Strong communication skills; Written and verbal
• Excellent critical thinking and problem - solving skills
• Candidate needs to be highly organized 
• Analytical, problem solving and decision-making skills; ability to exercise good judgment
• Ability to prioritize work, handle multiple tasks and work independently
• Ability to focus and learn in a remote setting as an independent contributor
• Strong attention 

͏

Deliver