This role is responsible for the resolution of customer inquiries coming from customers, brokers, providers, group secretaries and internal departments. The role is responsible for the evaluation of preauthorization requests, triaging these and referring cases to the corresponding clinical team.
The role is responsible for these functions for all Bupa Global members accessing care in the US through the BCBS agreement and in the case of Bupa Global Latinamerica members, also for the members accessing care through Olympus or any other US agreement.
The purpose is to evaluate preauthorization requests, deliver personalized service and provide support to members, brokers, providers and policy holders.
The role identifies and resolves member claims and customer questions, concerns or complaints with a sense of urgency in order to ensure customer satisfaction.
The role is responsible of handling the resolution of complaints and escalated issues regarding US Claims, preauthorization requests or other US service inquiries.
It follows local complaints management regulatory requirements and ensures compliance. Coordinates with other areas to resolve issues, concerns or complaints. Provides proactive follow up to open cases and complaint resolution.
Supports main contact center to resolve complex issues.
- Provides benefit and eligibility information to members, providers and brokers.
- Sends letter of authorization or denial and explanation of benefits based on policy conditions and or Non-Disclosure Review.
- Obtains clinical information for preauthorization requests and handles the request based on the established criteria
- Provides provider education on proper claim filing
- Provides organized system of care to our members by assisting with In-network provider search
- Reviews and analyzes documentation and cross reference systems to determine if claims have been correctly processed or if additional information or documentation is needed.
- Handles calls and emails from Business Partner’s, Brokers, Members and Service Centers within department expectations to meet company service objectives
- Manage claim related inquiries, notification and preauthorization questions via phone and email from members, providers or regional office within given deadlines and service objectives.
- Able to identify an incorrectly processed claim (i.e. incorrect case handling, payments and diagnosis) and able to cross reference claims among systems.
- Contact members, providers, brokers and or internal departments in order to respond to inquiries or to notify them of claim investigation results and any planned adjustments.
- Enters notes for every conversation, email and decision in the system(s) so that it is available Companywide.
- Point of contact for escalated calls or complaints.
- Escalates cases to the US network provider, where applicable and owns the resolution of these.
- Handles request for proof of insurance.
- Delivers personalized customer care to brokers and Policy holders by resolving issues personally, regardless of the question or issue, calls back with information or resolution within set deadlines, exceeding customer expectations.
- May receive visits from Policy holders visiting Miami.
- Supports the call center staff in order to meet customer service Key Performance Indicators.
- Performs other related tasks as assigned.
The Ideal Candidate
- College degree 4 years or equivalent in healthcare or business relevant experience preferred.
- 5 years of US centric healthcare experience preferred
- Significant customer service experience 5 years Required
- Experience in handling high-end “niche” customers to ensure high level degree of customer service satisfaction.
- Bilingual English and Spanish fluently read and write with excellent verbal communication skills in both languages. Required.
- High level experience with medical terminology and billing and coding preferred
- Sound knowledge of MS Office software
About the Company
Bupa Global is an Equal Opportunity Employer
Bupa is an equal opportunity employer and in compliance with the law prohibits discrimination against applicants and employees based on the following characteristics: veteran status, uniformed service member status, sex, race, color, ancestry, national origin, religion, age, marital status, sexual orientation, pregnancy, childbirth and related conditions, familial status, citizenship, sickle cell trait, AIDS/HIV status (actual or perceived), genetic information, testing or characteristics or any other legally recognized status entitled to protection under federal, state, and local anti-discrimination laws. Bupa’s Equal Employment Opportunity Policy applies to all applicants and employees with respect to all terms and conditions of employment, including recruitment, hiring, training, compensation, transfer, layoff recall, benefits, promotion and separation.