Title: Operations Specialist (Customer Navigator)
Duration: 12 months 
Location: The role is 100% remote, but candidates need to be from an approved conversion State (Alabama, Arizona, Arkansas, Colorado, Florida, Georgia, Idaho, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maryland, Michigan, Mississippi, Missouri, North Carolina, Ohio, Oklahoma, Pennsylvania, South Carolina, South Dakota, Tennessee, Texas, Utah, Virginia, Wisconsin, and Wyoming.
Shift: M-F 8-6 (The team rotates to working one late day once a week)

Job Description:

• Identify and document escalated, recurring, or complex system, process, and workflow problems; identify trends, recommend solutions/alternatives, and work to resolve issues.  
• Serve as a subject matter expert for employees’ inquiries and internal/external audits/projects around work process, procedures, products, and policies, and provide support, testing, coaching, or first-level escalation, and research support as needed.
• Provide cross-functional support and departmental expertise to varied internal stakeholders.
• Responsible for departmental reporting, tracking, and/or data analysis as needed.
• Perform quality reviews of inquiries to determine the accuracy of information provided and ensure employees are functioning at the expected level of service to enhance customer interaction.  
• Communicate the results of the reviews to improve individual and overall performance and make recommendations for coaching and training as necessary.
• Process a variety of transactions that may include suspended claims, inquiries, adjustments, and/or correspondence.
• Determine benefit eligibility on suspended claims for specific products by utilizing medical records, certificate/benefit provisions, and clinical knowledge.
• Act as a point of contact for compliance and communicate compliance needs to management staff. 
• Make direct high-volume outreach calls to targeted members utilizing effective engagement strategies and soft sales techniques to respectfully encourage members to engage in Case Management or Disease Management services.
• May place outbound calls to various providers, customers, or other outside contacts.
• Coach, educate, and guide members in case management and health program participation to increase enrollment and drive positive health outcomes for our members.
• May include coordinating relevant mailings of educational or other company materials to members.
• May support clinical staff through referrals, mailbox management, work assignment, and relevant documentation.
• May assist in the review and update of SOPs for Membership and key business partners.
• May handle more complex problems of eligibility and documentation with producers.
• May provide additional information to underwriting staff when submitting referrals for exception consideration.

Hiring Requirements:

• High school diploma or GED.
• 3+ years of experience in a related field.

Top 3-4 Required Skills:

• Organized, Customer service background.

Nice to have Skills:

• Being able to type and have Microsoft experience, Behavioral health background.

Years of Experience: 

• 3-5

Breakdown of Duties/Typical Day: 

• Look for providers for the member and connect the member with what they are looking for.

What does the training look like for this role? 

• 2-3 weeks with a trainer to go over the basics/department. Week 2 is when they will be paired with a preceptor and shadow.
• The third week is being monitored but able to work.

Do you have screening questions? 

• Share a time when you dealt with on-the-job pressure. What caused the pressure, and how did you overcome it?

 
 
At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws. This position’s starting pay is: $ 20.13/hr.