Customer Service Specialist 1 - Intellicare

JOB PURPOSE

Ensure effective and efficient delivery of best Customer Experience in assisting individual availments of members be it an outpatient and dental care by following the benefit plan and by supporting the cost management initiatives which will contribute to client retention.

1. Establish and build good provider relationship thru immediate open and accurate exchange of information: Answering inquiries and calls for approval
2. Establish and build good member relationship thru personalized and accurate exchange of information: Answering inquiries and calls for approval based on agreed Average Handling Time

Following Adjudication process:

1. Member’s information and account number should match database.
2. Doctor and facility is part of the network.
3. With access to said accredited facility.
4. Diagnosis and prescribed tests/procedures are related and within Intellicare availment disease guidelines.
5. Diagnosis and prescribed tests/procedures is within contract provision.
6. Limit is sufficient.
7. Amount of procedure is within CSS level of authority

• To support cost efficiency initiatives to affect the company’s bottom line
• Answering inquiries and calls for approval based on agreed Average Handling Time

1. Referral to Telemedicine (Medgate & TelAventus)
2. Aventus Clinics
3. Other cost efficient clinics/providers and recommended paneldoctors.
4. Accredited hospitals

• To mitigate abuse/fraudulent claims for approval are Red Flagged by following below process;

1. Diagnosis is not related to the diagnostic procedures.
2. Professional fee not in accordance with agreed schedule fees.
3. Same diagnostic procedures prescribed by same doctor to all patients seen (trending)
4. Physical Therapy sessions and modalities.

Note: To manage company exposure by following levels of authority in every approval

Senior High School Graduate and up

Preferably with work Experience as Customer Service Specialist in HMO setting or Medical facility is an advantage

Ability to work in shifting schedule and multi-task. Can work under pressure.

45 wpm typing skills