POSITION SUMMARY
Under the direction of the Customer Service Manager, performs duties related to the Customer Service department, that includes managing the acknowledgement and resolution of grievances and appeals from HDS members and providers, resolving member and provider escalations, coordinating and conducting Customer Service training, documenting FAQs, policies and procedures, evaluating and improving operational processes, identifying system / workflow issues and recommending solutions, analyzing call center data, generating weekly / monthly reports, monitoring and adjusting daily work schedules for Customer Service representatives, reviewing random samples of recorded calls and providing coaching / feedback, ensuring work processes are compliant with regulations, guidelines, and customer contracts, and assisting the Customer Service Manager in assuring company / department goals are met.
ESSENTIAL DUTIES AND RESPONSIBILITIES
Key Responsibilities
Utilizes comprehensive understanding of various claims payment scenarios for Medicaid, Medicare, and Commercial lines of business, HDS procedure code guidelines, diverse dentist office billing formats and practices, in-depth clinical explanations, the dentist / patient relationship, and HDS provider regulations.
Reviews, researches, and analyzes HDS claim payments, patient billing and payments, patient records, clinical notes maintained by the dental office, and potential discrepancies in patient billing and / or records to determine corrective action steps.
Develops training curriculum for the Customer Service department. Creates refresher training material for Customer Service team members.
Updates SharePoint as a common knowledge base and for ease of use and access.
Acts as the department liaison to Claims Processing, Membership Services, Billing, Professional Relations, Sales, Marketing, Underwriting and / or Information Systems for process / system improvements to enhance the overall customer experience.
Coordinates interdepartmentally to understand and mitigate periods of high call volume. Implements short term and long-term solutions to help reduce incoming call volume.
Develop Workflows to ensure that Customer Service has processes in-place for ongoing training. Monitors staff compliance with company policies and procedures and identifies / implements corrective action for potential breaches of HIPAA information.
Analyzes call center data and generates weekly / monthly / quarterly reports for employer groups and health plans. Tracks, updates, and reports Performance Guarantee results for Customer Service.
Assists with development and maintenance of department dashboards and spreadsheets.
This includes assisting with offline work, supervisory coverage, and / or extended shift coverage.
Other Duties and Responsibilities
MINIMUM QUALIFICATIONS AND EXPERIENCE
Education
Experience
Skills and Knowledge
e., Medicaid, Medicare, HIPAA, PHI).
Working knowledge of PC applications (Windows, Word and Excel) highly desirable for problem-solving, including ability to understand interrelationship of multiple system applications.
Note : The above information in this description has been designed to indicate the general nature and level of work performed by an employee in this classification.
It is not to be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications of employees assigned to this job.
Hawaii Dental Service has the right to add to, revise, or delete information in this description. Reasonable accommodation will be made to enable qualified individuals with disabilities to perform the essential functions of this position.
Last updated : 2024-04-23
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