Contact Center Representative II

Job Summary

The Contact Center Representative (CCR) II is the first point of contact for members, providers, and stakeholders, delivering complete, accurate and compassionate support on moderately complex issues related to eligibility, benefits, claims, authorizations, Primary Care Physician (PCP) changes, and other service needs ensuring seamless triage across the healthcare journey. The CCR II delivers a high-quality service experience that supports member retention and health outcomes.

The CCR II focuses on all managed care product lines, with an in-depth understanding of Commercial and Medicare products.

Duties

Responds to inquiries across all channels related to eligibility, benefits, claims, authorizations, and coordination of care. Assists members with navigating their healthcare journey, including understanding their eligibility and benefits, Evidence of Coverage (EOC) and Member Handbook. Provides First Call Resolution (FCR) by accessing internal tools and external portals to address the needs of our members and providers effectively on the first call. Supports members and providers with navigation of self-service tools. Resolves moderately complex issues requiring coordination with internal departments. Capture and reconcile premium billing payments, ensuring accurate calculation of member premiums. Initiates Service Authorization Requests (SARs). Documents all member interactions in L.A. Care’s system of record. Ensures compliance with Health Insurance Portability and Accountability Act (HIPAA) regulations and protects member privacy. Triages and directs calls to the appropriate internal teams or external entities for resolution, as needed. Maintain current knowledge of benefit plans, regulatory requirements, and internal policies to ensure compliant and accurate information delivery. (80%)

Supports ad-hoc targeted member outreach activities as determined by business need. (10%)

Performs other duties as assigned. (10%)

Duties Continued

Education Required

High School Diploma/or High School Equivalency Certificate

Education Preferred

Experience

At least 2 years of customer service contact center experience in a healthcare environment.

Data entry experience with ability to type a minimum of 40 wpm.

Skills

Ability to answer a high volume of calls while demonstrating a high level of empathy and patience.

Knowledge of managed care terminology, specifically in the commercial and Medicare space.

Familiarity with HIPAA regulations and confidentiality practices.

Strong verbal and written communication skills.

Strong probing, problem-solving and multitasking skills with attention to detail.

Strong understanding of healthcare operations including claims processing and benefits administration.

Proficient in contact center systems and Microsoft Office.

Preferred:
Bilingual in one of L.A. Care Health Plan’s threshold languages is highly desirable. English, Spanish, Chinese, Armenian, Arabic, Farsi, Khmer, Korean, Russian, Tagalog, Vietnamese.

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Light

Additional Information

L.A. Care Health Plan’s Contact Center is open 24 hours a day, 7 days a week, including holidays. Contact Center work shifts are assigned based on business need and may include, but not be limited to, evenings, weekends and holidays.