Sr Customer Care Specialist

Our work matters. We help people get the medicine they need to feel better and live well.  We do not lose sight of that. It fuels our passion and drives every decision we make.

Job Posting Title

Job Description

• This position is a frontline service position providing assistance to members and providers regarding programs, policies, and procedures. Responsibilities include answering incoming calls related to eligibility, benefits, claims and authorization of services from members or providers. Responsibilities also include the administration of intake documentation into the appropriate systems. Overall expectations is to provide outstanding service to internal and external customers and strive to resolve member and provider needs on the first call. Performance expectations are to meet or exceed operations production and quality standards.

  Responsibilities

  • Listens and probes callers in a professionally and timely manner to determine purpose of the calls.
  • Researches and articulately communicates information regarding member eligibility, benefits, EAP services, claim status, and authorization inquiries to callers while maintaining confidentiality.
  • Resolves customer administrative concerns as the first line of contact this may include claim resolutions and other expressions of dissatisfaction.
  • Assist efforts to continuously improve by assuming responsibility for identifying and bringing to the attention of responsible entities operations problems and/or inefficiencies.
  • Assists in the mentoring and training of new staff.
  • Assumes full responsibility for self-development and career progression; proactively seek and participate in ongoing trainings (formal and informal).
  • Assembles and enters patient information into the appropriate delivery system to initiate the EAP, Care and Utilization management programs.
  • Demonstrates flexibility in areas such as job duties and schedule in order to aid in better serving members and help achieve its business and operational goals.
  • Educates providers on how to submit claims and when/where to submit a treatment plan.
  • Identifies and responds to Crisis calls and continues assistance with the Clinician until the call has been resolved.
  • Informs providers and members on appeal process.
  • Leads or participates in activities as requested that help improve Care Center performance, excellence and culture.
  • Links or makes routine referrals and triage decisions not requiring clinical judgment.
  • Performs necessary follow-up tasks to ensure member or provider's needs are completely met.
  • Provides information regarding in-network and out-of-network reimbursement rates and states multiple networks to providers.
  • Refers callers requesting provider information to Provider Services regarding professional provider selection criteria and application process.
  • Refers patients/EAP clients to the Care Management team for a provider, EAP affiliate, or Facility.
  • Updates self on ever changing information to ensure accuracy when dealing with members and providers.
  • Supports team members and participate in team activities to help build a high-performance team.
  • Documents customers comments/information and forwards required information to the appropriate staff.

  Education & Experience

  Education Level

  • Required: High School, GED
  • Preferred: Associates, Bachelors

  Experience Level

  • Required: 2+ years Customer Service

  Must be eligible to work in the United States without the need for work visa or residency sponsorship.

  Additional Qualifications

  • Must be flexible in scheduling and comfortable with change as customer service is an ever-changing environment.
  • Responsible for meeting call handling requirements and daily telephone standards as set forth by management.
  • Must agree to observing service for the purpose of training and quality control.
  • Must be a proficient typist (avg. 35+ WPM) with strong written and verbal communication skills.
  • Must be able to maneuver through various computer platforms while verifying information on all calls.
  • Must be able to talk and type simultaneously.

  Preferred Qualifications

  • PBM Experience

  Physical Demands

  • Must be able to remain in a stationary position 50% of the time. Must be able to "move or traverse"
  • Must be able to constantly operate a computer and/or other office productivity equipment
  • Must be able to hear and constantly communicate information and ideas. Must be able to exchange accurate information
  • Occasionally required to lift and/or move up to 10 pounds and occasionally lift and/or move up to 25 pounds

  Every employee must understand, comply with and attest to the security responsibilities and security controls unique to their job, and comply with all applicable legal, regulatory, and contractual requirements and internal policies and procedures.

Prime Therapeutics LLC is proud to be an equal opportunity and affirmative action employer. We encourage diverse candidates to apply, and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sex (pregnancy, sexual orientation, and gender identity), national origin, disability, age, veteran status, or any other legally protected class under federal, state, or local law.   

We welcome people of different backgrounds, experiences, abilities, and perspectives including qualified applicants with arrest and conviction records and any qualified applicants requiring reasonable accommodations in accordance with the law.

Prime Therapeutics LLC is a Tobacco-Free Workplace employer.

Positions will be posted for a minimum of five consecutive workdays.