Member Service Representative

Position Description

Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more. 

At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.”

Customer Service Representative is responsible for providing efficient, courteous, professional quality service to members, providers, group administrators, brokers, Plan personnel, and the general public in a timely manner. Inquiries are received via telephone, Fax, written correspondence (Imaging), E-mail, E-messenger Internet, and personal interviews. Inquiries cover topics pertaining to enrollment, billing, benefits, and claims for various types of coverage offered by CBC. Provides support for the Marketing department, serving as a liaison for group administrators, brokers, and assisting in servicing accounts.

Responsibilities and Qualifications

• Receives incoming inquiries via telephone, correspondence, on-site, Fax, Internet, E-mail and personal interviews from individual customers, group administrators, providers, Capital BlueCross personnel, Host Plan personnel, attorneys, and outside entities working on the customer's behalf.
• Researches and analyzes the customer's inquiry. Determines appropriate action by reviewing and interpreting applicable policies/procedures. Utilizes the PC, manuals, Image, etc., to obtain benefits, enrollment and claim information.
• Ensures the satisfactory resolution of routine and moderately complex inquiries (e.g., Blue Card) benefits, claim filing and processing, collection issues, enrollment discrepancies, legal requests, Medicare Secondary Payor, Plus Billing and payment requests, Third Party Administrators, COBRA, reinstatements, conversions, refunds, new enrollment, transfer situations, student certifications, handicapped dependents) for all lines of business administered and supported by Capital BlueCross.
• Provides clear and concise instructions to the appropriate Plan area, in the approved format (e.g., electronic, on-line or hard copy forms, telephone contact) for the resolution of the issues.
• Contacts the appropriate internal/external entities (e.g., groups, providers, Marketing, Legal, host plans) to obtain information and initiate necessary action.
• Responds to customers, verbally or in writing, with accurate and timely information.
• Monitors inquiries for accurate and timely resolution to ensure customer satisfaction and compliance with MTM quality and timeliness guidelines.
• Enters all information necessary to update the Facets system, or Inquiry Control System when appropriate, for tracking inquiry action and status. Utilizes the system to obtain background information and prevent duplication of effort.
• Reports inquiry trends to management that may indicate processing problems, lack of documentation or appropriate information concerning claims, enrollment areas, benefits, policies and procedures.
• Assists/participates with Marketing personnel and the broker community in the support of customer needs by researching and communicating information to other Plan personnel or directly to the customer. May attend or participate in marketing related activities as a representative of Capital BlueCross Customer Service (e.g., health fairs, seminars, open enrollment, and on-site visits).

Experience:

• Must have a high school diploma or G.E.D.
• 1 year customer service experience.
• Demonstrates ability to understand and interpret detailed policies and procedures and to be able to apply them to various situations. This includes thorough understanding of CBC’s responsibility to maintain privacy of Protected Health Information as required by the Health Insurance Portability and Accountability Act.
• Demonstrates ability to work independently, be flexible and react appropriately to changing job assignments and work environments.
• Demonstrates ability to communicate effectively and professionally both verbally and in writing with all levels of internal/external personnel in order to respond to customer inquiries ranging from routine to complex and involving sensitive subject matter.
• Demonstrates analytical, organization and problem-solving skills in order to accurately and efficiently identify, analyze and respond to customer inquiries, as well as identify and analyze trends and discrepancies.
• Ability to use telephone equipment systems such as Interactive Voice Response and Automated Call Distribution.
• Familiarity with the utilization of a PC and various software such as Microsoft Office Suite.

Physical Demands:

• Sedentary work involving significant periods of sitting, talking, hearing, keying and performing repetitive motions. Work requires visual acuity to perform close inspection of written and computer-generated documents as well as a PC monitor. Working environment includes typical office conditions.

About Us

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a caring team of supportive colleagues, and be encouraged to volunteer in your community.  We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career.     And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.