Customer Service Rep Sr. - SUNSHINE ENTERPRISE USA LLC

Sunshine Staffing is seeking Customer Service Rep Senior! This individual is communicative, organized, and responsible. They will be using problem-solving skills to address matters of eligibility, verification, and other day-to-day services.

• Addresses member inquiries, questions and concerns in all areas including enrollment, claims, benefit interpretation, and referrals/authorizations for medical care.
• Verifies member eligibility, claim and authorization status for providers.
• Responsible for thorough follow-up and completion of all member and provider inquires or requests.
• Responsible for accurate, complete, and correct documentation into Facets regarding all issues, inquires, complaints and grievances.
• Functions efficiently and productively in a high-volume call center.
• Maintains departmental productivity and quality standards.
• Provides follow-up assistance as needed.
• Routes escalated calls to the appropriate Member Liaison Specialist, Supervisor or Call Center Manager.
• Adheres to departmental policies and procedures.
• Processes all member transportation request within one business day of receipt and coordinating all aspects of the process with the clinic, provider, and member as appropriate or necessary.
• Assists members with our Web Portal registration and technical support.
• Interacts face-to-face with members by assisting with front desk coverage.
• Serves as a backup for Customer Service Leads, as needed.
• Handles and resolves escalated issues.

• 2 years of Health Maintenance Organization (HMO), Medi-Cal/Medicaid and health services experience preferred.
• High School diploma or equivalent required.
• 2 years of experience in a customer/member service or call center capacity required.
• An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying.
• Bilingual in English and in Arabic, Farsi, Chinese, Korean, Spanish, or Vietnamese required.

• Establish and maintain effective working relationships with CalOptima Health's leadership and staff.
• Function efficiently and productively in a high-volume call center.
• Learn procedures and regulations governing member eligibility and the terminology and documents used while remaining knowledgeable of CalOptima Health/Medi-Cal benefits and procedures.
• Hear and speak well enough to converse on the phone and in person.
• Understand and follow oral and written directions.
• Speak, understand, read and/or write a second language in addition to English may be required for some assignments.
• Communicate clearly and concisely, both orally and in writing.
• Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems (e.g., Facets) to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.
• Principles and practices of managed health care, health care systems, and medical terminology.
• Principles and techniques for handling customer service issues.
• Personal computers, keyboarding, and appropriate software to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.
• Customer service principles and practices.

•Competitive pay & weekly paychecks

•Health, dental, vision, and life insurance

•401(k) savings plan

•Awards and recognition programs

•Benefit eligibility is dependent on employment status.