Call Center Representative, Escalation Team

Amida Care, the largest Medicaid HIV Special Needs Plan in NY, delivers a uniquely effective care model that has become a true benchmark for innovation, engagement and member health outcomes. Our mission is to provide access to comprehensive care and coordinated services that facilitate positive health outcomes and general well-being for our members. This true integrative care model addresses psychosocial, housing, behavioral and medical services directly evolving around the needs of each member.

We are a community of individuals from diverse peoples who work together to actively foster a fair, equitable, inclusive environment where all employees receive an invitation to belong. Visit [webpage] for more information about the Amida Care culture.

We are actively seeking a highly motivated, innovative and experienced leader to join our team as the Senior Director of Provider Relations. This position will be a member of the senior management team. Compensation will be commensurate with experience.

Position Summary:

The Call Center Representative, Escalation Team acts as a subject-matter expert and is responsible for day to day intake, research and analysis, data gathering and documentation, resolution of complex member and provider inquiries, and claims issues. This role provides live call support to members and providers on a variety of subjects including all traditional Member Services call types and provider centric issues including claims, contracting, fee schedule queries, appeals and managed care procedural queries. Assist by taking calls, answering questions, and providing guidance and mentoring call center staff. Enhance member and other customer experience by providing efficient and timely solution delivery. This position elicits opportunities for operational and experience improvement and engages with call center management on cross functional initiatives to improve customer experience across the service delivery platform.

The Call Center Representative, Escalation Team must be able to work well under pressure to meet deadlines, thrive on attention to detail, exhibit a high level of accuracy, and possess excellent communication skills, both written and verbal.

Responsibilities:

Field, triage and resolve complex member and provider inquiries with regard to claims, authorizations, eligibility, and benefits, including those escalated by TPA
Research, escalate, and route provider and member inquiries within Amida Care or associated vendors as appropriate; ensure follow through with customers
Identify and surface reoccurring issues, customer feedback and other opportunities for improvement to call center management
Participate in individual coaching as well as team and department training
Work collaboratively and provide support and guidance to call center and customer touch point staff across the service organization
Resolve provider issues that may cross departmental lines and involve management team
Assist with training/coaching of other call center representatives as appropriate
Good understanding of medical billing, and claims processing systems
Ability to analyze, document and implement processes and procedures as prescribed by Plan policies
Research, escalate, and route provider and member inquiries within Amida Care or Associated Vendors as appropriate; ensure follow through with the providers/members

Amida Care is Diversity, Equity and Inclusion employer committed to full inclusion and elimination of discrimination in all its forms. We strive to develop, promote and sustain a culture that values equity and leverages diversity and inclusiveness in all that we do.

Amida Care requires that all candidates selected for employment must provide proof of full Covid-19 Vaccination upon acceptance of an offer of employment.

EDUCATION REQUIRED

Bachelor’s Degree in health care, business or similar, or an equivalent combination of directly related experience

EXPERIENCES AND/OR SKILLS REQUIRED

Must have strong health plan knowledge with minimum of three (3) years of customer service, provider service, and claims experience in a call center setting
Bi-lingual English and Spanish strongly preferred
Salesforce or other CRM experience is a plus
Effective communication (verbal and written) and presentation skills with the ability to communicate to a variety of stakeholders within the organization, providers, vendors, and outside organizations
Knowledge of process improvement methodologies desired
Demonstrate understanding and sensitivity to multi-cultural values, beliefs, and attitudes of both internal and external contacts
Demonstrate appropriate behaviors in accordance with the organization’s vision, mission, and values.

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