Overview Responds to all incoming correspondence and telephone inquiries directly related to the position in a professional manner consistent with the health system's mission. Attend seminars/training sessions. They may be required to work overtime during peak periods. Performs other duties as assigned. Responsibilities Essential Duties and Responsibilities Serve as a resource or Subject Matter Expert (SME) for other team members or internal members in the following areas: WI and Illinois Group EPO, HMO, PPO, POS lines of business WI and Illinois Individual Marketplace WI Medicaid WI Medicare Supplemental Insurance WI and Illinois Pharmacy Riders Handle escalated calls, resolving more complex member issues in a one-and-done manner Answer incoming phone calls from members and identify the type of assistance the member needs- Members or someone calling on behalf of members Providers Pharmacy Ask appropriate questions and listen actively to identify specific questions or issues while documenting required information in computer systems Assist members in navigating Mercyhealth’s websites and encourage and reassure them to become self-sufficient Assist members in choosing a primary care physician and scheduling their first appointment or when assistance getting an appointment is asked for by the member Own problem through to resolution on behalf of the member in real-time or through comprehensive and timely follow-up with the member Research complex issues across multiple databases and work with support resources to resolve member issues and/or partner with others to resolve escalated issues Provide education and status on previously submitted pre-authorizations or pre-determination requests Responsible for entering all approved authorizations into the pharmacy benefit management system. Also responsible for entering overrides to ensure members receive their prescriptions promptly. Assist in taking premium payments from members for our marketplace line of business. Meet the performance goals established for the position in the areas of first-call resolution, service level, occupancy rate, percentage of calls held, redirect, attendance, NCQA required audits, and any contractual requirements (ETF, Medicaid, etc.) Culture of Excellence Behavior Expectations To perform the job successfully, an individual should demonstrate the following behavior expectations: Quality - Follows policies and procedures; adapts to and manages changes in the environment; Demonstrates accuracy and thoroughness giving attention to details; Looks for ways to improve and promote quality; Applies feedback to improve performance; Manages time and prioritizes effectively to achieve organizational goals. Service - Responds promptly to requests for service and assistance; Follows the Mercyhealth Critical Moments of service; Meets commitments; Abides by MH confidentiality and security agreement; Shows respect and sensitivity for cultural differences; and effectively communicates information to partners; Thinks system wide regarding processes and functions. Partnering - Shows commitment to the Mission of Mercyhealth and Culture of Excellence through all words and actions; Exhibits objectivity and openness to other's views; Demonstrates a high level of participation and engagement in day-to-day work; Gives and welcomes feedback; Generates suggestions for improving work: Embraces teamwork, supports and encourages positive change while giving value to individuals. Cost - Conserves organization resources; Understands fiscal responsibility; Works within approved budget; Develops and implements cost saving measures; contributes to profits and revenue. Education and Experience High school education Certification and Licensure N/A Skills and Abilities Excellent oral communication skills/organizational skills Ability to handle stress Microsoft Word & Excel Knowledge of health insurance is desirable Knowledge of Epic software Tapestry desirable Knowledge of coding/medical terminology desired Ability to assist staff Special Physical Demands While performing the duties of this Job, the employee is regularly required to sit, talk, and hear. The employee is frequently required to use hands to finger, handle, or feel and reach with hands and arms. Specific vision abilities required by this job include close vision, peripheral vision, and the ability to adjust focus. The employee is occasionally exerting up to 20 pounds of force. Must use a computer, keyboard, mouse, and specific computer programs as required. Level of Supervision Some independent judgment is required, but alternatives are limited by standard practices or procedures. Supervises N/A