Santa Clara Family Health Plan · 5 hours ago
Customer Service Representative I
San Jose, CA
Full-time
Onsite
Entry Level
$55K/yr - $79K/yr
1+ years expSanta Clara Family Health Plan is seeking a Customer Service Representative I to support their Customer Service Department operations. The role involves answering inbound and making outbound calls to assist members and providers while ensuring compliance with regulatory requirements and achieving service-level objectives.
CommunitiesHealth CareInsurance
Responsibilities
Act as the primary point of contact and liaison for SCFHP members and providers contacting the plan regarding general inquiries, concerns or requests for information
Develop a general understanding of all member facing materials, communications and interactions and be prepared to respond appropriately to follow up calls
Answer inbound calls and/or place outbound calls in a high call volume environment and work directly with members and providers to accurately and completely answer inquiries involving SCFHP program services and benefits
Follow established guidelines and resources to respond to member and provider inquiries and resolve concerns in an accurate, timely, professional, and culturally competent manner
Intake, handle and coordinate member grievances, appeals and billing issues, escalating to the Grievance and Appeals department, when necessary
Educate members and providers on eligibility, and medical and pharmacy benefits and how to access services in a manner that achieves excellent service standards and maintains high customer satisfaction
Use listening skills and judgment to appropriately categorize and accurately document all contacts and follow-up actions regarding member and provider communications and activities in accordance with established guidelines
Appropriately handle member and provider requests through alternative channels such as e-mail, voicemail, fax, walk-in, etc. in accordance with established procedures
Triage member and provider requests or inquiries for other departments
Conduct member surveys as assigned in accordance with established guidelines
Attend and actively participate in daily, weekly, and monthly departmental meetings, in-services, training and coaching sessions
Identify member/provider issues and trends and report relevant information to management
Perform other related duties as required or assigned
Qualification
Required
High School Diploma or GED
Minimum one year of experience in Customer Service or Call Center role, preferably within a Health Care, Public Assistance or Human Services programs
Ability to meet Key Performance Indicators by participating in and achieving the standards of the Customer Service Call Center Quality Program
Working knowledge of and the ability to efficiently operate all applicable computer software including computer applications, such as Outlook, Word and Excel
Ability to use a keyboard with moderate speed and a high level of accuracy
Excellent communication skills including the ability to express oneself clearly and concisely when providing service to SCFHP Plan members and providers over the telephone, in person or in writing
Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes
Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position
Ability to maintain confidentiality
Ability to comply with all SCFHP policies and procedures
Ability to perform the job safely with respect to others, to property, and to individual safety
Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time
Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds
Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less
Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment
Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone
Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail
Preferred
Prior experience with managed care plans, Medi-Cal and Medicare programs, and working with underserved populations
Spanish, Vietnamese, Chinese, or Tagalog language bi-lingual skills
Company
Santa Clara Family Health Plan
Santa Clara Family Health Plan is a local and community-based health plan dedicated to improving the health and well-being of the residents.
201-500 employees
Funding
Current Stage
Growth StageLeadership Team
Teresa Chapman
Chief People Officer
Recent News
2025-10-30
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