Concierge representative exclusive provider organization Job at Advocate Aurora Health (Rolling Meadows)

Job Responsibility

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
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
Deescalate callers that are distraught or upset due to real or perceived difficulties they have encountered
Follow appropriate scripts and procedures
Retrieve and respond to all voicemail messages within one business day
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
Researching eligibility disputes
contacting Managed Care Organization, HR Direct, ADP, etc. to resolve outstanding concerns on behalf of the Advocate associate
Complete documentation of telephone inquiries utilizing the established call documentation database
Manage follow-up timely for any open/unresolved escalations
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
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
Assures that denied claims and referral/waivers are rectified in timely manner as appropriate
Intervenes to diffuse member call/accounts in collection contacting agencies to make adjustments or hold while issue is researched
Prompt and accurate handling of routine and non-routine customer service inquiries
Take ownership for each contact and provide consistent, high quality customer service that matches the marketing image and brand of Advocate Health Care
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
Using a translation service when language other than English is preferred means of communication as necessary
Conducts calls in accordance with all metrics and measure used to evaluate call quality & productivity measures
Responsible for self-assessment of customer inquiries and escalation of high reliability events
Call monitoring will be reviewed on a monthly basis and recommendations for self-improvement will be discussed during coaching sessions
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
Reviews causes for billing errors and assists providers in making appropriate corrections
Reports potential issues with Ingenix and IDX
Reviews risk grids and educates providers, MCO representatives and others regarding payment responsibilities
Reports potential system errors via CCIRP
Assist members and physician office staff in checking referral status in computer
Researches referrals for members
Reviews, obtains and verifies accurate information on dictionary vendor request forms for loading or changing of new/existing contracted providers
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
Responsible for initiating calls to MCO, or any other entity tied to the benefits for Advocate associates

Requirements

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
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
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

What we offer

Paid Time Off programs
Health and welfare benefits such as medical, dental, vision, life, and Short- and Long-Term Disability
Flexible Spending Accounts for eligible health care and dependent care expenses
Family benefits such as adoption assistance and paid parental leave
Defined contribution retirement plans with employer match and other financial wellness programs
Educational Assistance Program
Premium pay such as shift, on call, and more based on a teammate's job
Incentive pay for select positions
Opportunity for annual increases based on performance

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Concierge representative exclusive provider organization

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