Healthcare Call Center Representative

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  • 20-00035
  • Full Time/Contract
  • Recruiting
  • Rancho Cucamonga, CA
Job Description
Healthcare Call Center Representative 

Under the general direction of the Provider Call Center Supervisor, the Provider Call Center Representative is responsible for responding to Provider calls in a friendly, professional manner. The Provider Call Center Representative must be able to utilize all policies and resources to answer questions and direct Providers in order to resolve their concerns.

  • Complete a comprehensive six-week training to develop proficiency and well-rounded knowledge of all Healthplan lines of business, claims processing/payments, Member benefits, Utilization Review, vision, behavioral health, HealthPlan's Provider Portal, and Act as a Provider Advocate.
  • Provide excellent customer service to all callers. Demonstrate a high level of patience and respect with every caller, avoid distractions ensuring each caller is assisted promptly and appropriately and follow Provider Call Center established call handle Quality Assurance Standards and Objectives.
  • Adhere to Provide Services Call Center Standard Work and performance expectations that includes, but is not limited to the following:
    • Active participation in continuous training.
    • Maintain 90% or above schedule adherence.
    • Maintain 90% or above calls quality assurance scores.
    • Handle an average of 60 inbound/outbound calls per day.
    • Strict adherence to specific work schedule and Healthplan Attendance and Punctuality Policy.
    • Participate in Provider Call Center meetings, which are held approximately twice a month from 7:00am to 8:00am.
    • Maintain standards for Provider and Member Rights and Responsibilities, such as maintaining Provider and Member confidentiality
  • Research contracted and non-contracted Provider calls related to claims payments and discrepancies, referrals submission and benefits, vision authorizations, behavioral health, and overall health plan general information.
  • Demonstrate extensive knowledge of all Healthplan product lines (Medi-Cal, DualChoice, and Healthy Kids) and ability to transfer knowledge to all callers' inquiries. Assist with general question about the Healthplan Member benefits and Healthplan Programs (such as P4P, Provider Network Expansion Fund & Provider Capital Fund, rosters, health education, how to join the Healthplan Provider Network,).
  • Support LEAN activity by actively participating in daily huddles to identify and discuss opportunities to improve and maintain department's performance.
  • Following standard work, ensure that each call is thoroughly documented and cases tasked to appropriate departments for follow-up and action. Ensure to follow-up on unresolved cases and communicate with Providers in a timely manner.
  • Ensure the privacy and security of PHI (Protected Health Information) as outlined in Healthplan's policies and procedures relating to HIPAA compliance


  • H.S. Diploma or GED REQUIRED
  • One (1) or more years' experience working in a call center required with healthcare call center experience preferred
  • One (1) or more years' experience working in Managed Care, HMO or IPA preferred
  • Proficient with MS Word, Excel and PowerPoint
  • Proficient written, verbal, communication and interpersonal skills
  • Ability to maintain effective working relationships with all staff
  • Ability to type at 45 WPM or faster
  • Knowledge of DualChoice Product preferred
  • Knowledge of Medicare and Medi-Cal preferred


  • $16.41/hr.
  • Full-Time | Contract Assignment


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