job

About Us:

Santa Clara Family Health Plan (SCFHP) is a local, community-based health plan dedicated to improving the health and well-being of the residents of Santa Clara County. Working in partnership with providers and community organizations, we serve our neighbors through our Medi-Cal and SCFHP DualConnect (HMO D-SNP) health care plans.

About the role:

The Customer Service Representative I answers inbound calls and makes outbound calls to support Customer Service Department operations in a manner that maintains compliance with Medicare and Medi-Cal regulatory requirements and achieves Call Center service-level objectives.

Day to Day:

Act as the primary point of contact and liaison for SCFHP members and providers contacting the plan regarding general inquiries, concerns or requests for information.

Develop a general understanding of all member facing materials, communications and interactions and be prepared to respond appropriately to follow up calls.

Answer inbound calls and/or place outbound calls in a high call volume environment and work directly with members and providers to accurately and completely answer inquiries involving SCFHP program services and benefits.

Follow established guidelines and resources to respond to member and provider inquiries and resolve concerns in an accurate, timely, professional, and culturally competent manner.

Intake, handle and coordinate member grievances, appeals and billing issues, escalating to the Grievance and Appeals department, when necessary.

Educate members and providers on eligibility, and medical and pharmacy benefits and how to access services in a manner that achieves excellent service standards and maintains high customer satisfaction.

Use listening skills and judgment to appropriately categorize and accurately document all contacts and follow-up actions regarding member and provider communications and activities in accordance with established guidelines.

About You:

High School Diploma or GED.

Minimum one year of experience in Customer Service or Call Center role, preferably within a Health Care, Public Assistance or Human Services programs.

Prior experience with managed care plans, Medi-Cal and Medicare programs, and working with underserved populations is desired.

Ability to meet Key Performance Indicators by participating in and achieving the standards of the Customer Service Call Center Quality Program.

Spanish, Vietnamese, Chinese, or Tagalog language bi-lingual skills is desired.

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