Customer Experience Administrator

POSITION SUMMARY

Under the direction of the Customer Service Manager, performs duties related to the Customer Service department, that includes managing the acknowledgement and resolution of grievances and appeals from HDS members and providers, resolving member and provider escalations, coordinating and conducting Customer Service training, documenting FAQs, policies and procedures, evaluating and improving operational processes, identifying system/workflow issues and recommending solutions, analyzing call center data, generating weekly/monthly reports, monitoring and adjusting daily work schedules for Customer Service representatives, reviewing random samples of recorded calls and providing coaching/feedback, ensuring work processes are compliant with regulations, guidelines, and customer contracts, and assisting the Customer Service Manager in assuring company/department goals are met.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Key Responsibilities

• Grievance and Appeals Process

• Coordinates the timely completion of HDS's grievance and appeals process, including acknowledging, researching, and resolving complaints and appeals from HDS members and dentists. Utilizes comprehensive understanding of various claims payment scenarios for Medicaid, Medicare, and Commercial lines of business, HDS procedure code guidelines, diverse dentist office billing formats and practices, in-depth clinical explanations, the dentist/patient relationship, and HDS provider regulations. Reviews, researches, and analyzes HDS claim payments, patient billing and payments, patient records, clinical notes maintained by the dental office, and potential discrepancies in patient billing and/or records to determine corrective action steps.

• Researches, investigates, and reports possible situations of fraud and abuse during the investigation of a grievance or appeal.

• Training

• Provides quality training and onboarding for new Customer Service Representatives. Utilizes side-by-side coaching and recorded call data to provide constructive feedback and quality assurance to new and existing call center representatives. Develops training curriculum for the Customer Service department. Creates refresher training material for Customer Service team members. Updates SharePoint as a common knowledge base and for ease of use and access.

• Acts as the department liaison to Claims Processing, Membership Services, Billing, Professional Relations, Sales, Marketing, Underwriting and/or Information Systems for process/system improvements to enhance the overall customer experience. Coordinates interdepartmentally to understand and mitigate periods of high call volume. Implements short term and long-term solutions to help reduce incoming call volume.

• During system outages, assists with implementing workaround processes, interdepartmental communications and normalizing call center operations, post-outage.

• Testing

• Conduct testing of HDS Byte, HDSView, Salesforce, Amazon Connect, and other HDS applications and systems to ensure optimal performance.

• Identify and troubleshoot any issues or bugs within these systems, working closely with ITS department.

• Develop Jira (or end user) stories and test cases in support of testing.

• Familiar with UAT test environments, regression testing, and required documentation.

• Update and maintain system documents, including testing protocols and results.

• Develops Job Aids, FAQs, policies, and procedures for the Customer Service department. Updates SharePoint to maintain the CS knowledge library for Customer Service. Develop Workflows to ensure that Customer Service has processes in-place for ongoing training. Monitors staff compliance with company policies and procedures and identifies/implements corrective action for potential breaches of HIPAA information.

• Analyzes call center data and generates weekly/monthly/quarterly reports for employer groups and health plans. Tracks, updates, and reports Performance Guarantee results for Customer Service. Assists with development and maintenance of department dashboards and spreadsheets.

• Assists Customer Service Representatives with escalations and issue resolution for member and provider calls. Contacts members and/or providers to follow-up and provide resolution.

• Serves as a back-up in the daily operations of the Call Center in the event of high call volume, staffing shortages, or to meet Performance Guarantee results. This includes assisting with offline work, supervisory coverage, and/or extended shift coverage.

Other Duties and Responsibilities

• Assists management staff in Dental Operations in managing the daily operations and working on special projects and initiatives, as needed.

• Other miscellaneous duties and responsibilities as assigned.

MINIMUM QUALIFICATIONS AND EXPERIENCE

Education

• High School Diploma or its equivalent required.

• Bachelor's degree in any discipline preferred or an equivalent combination of education, training, or work experience.

Experience

• Minimum of 3 - 5 years of experience in Customer Service, preferably in the areas of servicing customers and providers and researching dental claims payments

• Demonstrated work experience in oral and written customer communication and effective presentation of research, analysis, and reviews.

Skills and Knowledge

• Strong analytical skills, including the ability to define problems, collect and organize data, analyze, and understand various sources of information and problem-solve complex problems.

• Self-motivated, pursues job knowledge, and self-development

• Mindset of continuous improvement and finding new and better ways of performing the job, seeking solutions, and exercising good judgment.

• Ability to evaluate overall effectiveness and impact of process changes.

• Ability to learn, thoroughly comprehend and communicate regulations and related HDS policies.

• Ability to conduct thorough research and analyze situations from different perspectives

• Requires organization and ability to manage multiple tasks and maintain focus with attention to detail.

• Ability to work under minimal supervision.

• Ability to handle all information in a confidential manner and in compliance with federal and state laws/regulations (i.e., Medicaid, Medicare, HIPAA, PHI).

• Working knowledge of PC applications (Windows, Word and Excel) highly desirable for problem-solving, including ability to understand interrelationship of multiple system applications.

Note: The above information in this description has been designed to indicate the general nature and level of work performed by an employee in this classification. It is not to be interpreted as a comprehensive inventory of all duties, responsibilities, and qualifications of employees assigned to this job. Hawaii Dental Service has the right to add to, revise, or delete information in this description. Reasonable accommodation will be made to enable qualified individuals with disabilities to perform the essential functions of this position.