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Role Description

The clinical member services agent (CMSA) is responsible for providing effective customer service for all internal and external customers by using excellent, in-depth knowledge of company products and programs as well as communicating effectively with team members within the clinical department. The CMSA will work in conjunction with the member service agent to assist in clinical situations and resolutions.

• Knowledge of principles and processes for providing customer and personal services, including customer needs assessment, meeting quality standards for services, and evaluation of customer satisfaction.
• Confer with customers by telephone to provide information about Rx claims processing.
• Understanding of Pharmacy terms and formularies as a certified Pharmacy Technician (CPhT).
• Keep detailed records of customer interactions or transactions, recording details of inquiries, complaints, or comments, as well as actions taken.
• Follow-up to ensure that appropriate changes were made to resolve customers' problems.
• Refer unresolved customer grievances to designated departments for further investigation.
• Review Rx insurance policy terms to determine whether a claim is covered for employer group.
• Contact customers to respond to inquiries or to notify them of claim investigation results or any planned adjustments.
• Resolve customers' service or billing complaints.
• Obtain and examine all relevant information to assess validity of complaints and to determine possible causes.
• Abide by all obligations under HIPAA related to Protected Health Information (PHI).
• If a HIPAA violation is discovered, report the violation to the Compliance Officer and/or Human Resources.
• Attend, complete, and demonstrate competency in all required HIPAA Training offered by the company.
• Flexibility to understand, appreciate and embrace that this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee.

Qualifications

• High School or equivalent.
• Customer service experience.
• Certified Pharmacy Technician Certification (CPhT) with experience in a pharmacy setting.
• Computer experience.

Requirements

• Interacting with Computers — Using computers and computer systems (including hardware and software) to program, write software, set up functions, enter data, or process information.
• Communicating with Supervisors, Peers, or Subordinates — Providing information to supervisors, co-workers, and subordinates by telephone, in written form, e-mail, or in person.
• Getting Information — Observing, receiving, and otherwise obtaining information from all relevant sources.
• Communicating with Persons Outside Organization — Communicating with people outside the organization, representing the organization to customers, the public, government, and other external sources.
• Processing Information — Compiling, coding, categorizing, calculating, tabulating, auditing, or verifying information or data.
• Resolving Conflicts and Negotiating with Others — Handling complaints, settling disputes, and resolving grievances and conflicts.
• Updating and Using Relevant Knowledge — Keeping up-to-date technically and applying new knowledge to your job.
• Organizing, Planning, and Prioritizing Work — Developing specific goals and plans to prioritize, organize, and accomplish your work.
• Performing Administrative Activities — Performing day-to-day administrative tasks such as maintaining information files and processing paperwork.
• Making Decisions and Solving Problems — Analyzing information and evaluating results to choose the best solution and solve problems.
• Customer and Client Focus.
• Problem Solving and Analysis.
• Time Management.
• Communication Proficiency.
• Teamwork Orientation.
• Technical Capacity.
• Multitasking.
• Competencies as a Certified Pharmacy Technician (CPhT).

Benefits

• Medical, Dental, Vision Insurance
• Disability and Life Insurance
• Employee Assistance Program
• Remote work options
• Generous Paid-Time Off
• Annual Reviews and Development Plans
• Retirement Plan with company match, immediately 100% vested

Position Type and Expected Hours of Work

This is a full-time, hourly position. Days and hours of work vary on shift assigned. The Call Center hours of operation are Monday – Friday 6a – 10p, Saturday 8a – 6p, and Sunday 8a-5p. On-Call responsibilities are on a rotation basis. This position reports to the Contact Center Supervisor.

Travel

Minimal travel expected for this position to Natchitoches, Louisiana for training and development.