Customer Service Representative

Description

Position Summary
We are seeking a dedicated Customer Service Representative to join our team. This role serves as a key point of contact for medical provider offices, members, group administrators, and internal departments, delivering accurate, timely, and courteous support across a high volume of inbound and outbound calls.

Essential Duties and Responsibilities

1. Respond to a high volume of inbound calls from medical provider offices, members, group administrators, and other stakeholders.
2. Communicate and coordinate effectively with internal departments, including Group Administration, Individual Administration, Electronic Eligibility, and Client Services.
3. Listen attentively to caller questions and concerns, responding accurately and in a timely manner.
4. Meet call audit standards and operational expectations, including availability, call quality, and average call handle time, along with other individual and departmental metrics.
5. Document and maintain clear, accurate call records that can be easily interpreted by other internal staff.
6. Escalate calls appropriately in accordance with internal guidelines and procedures.
7. Research claim-related issues to ensure accurate and informed responses to inquiries.
8. Maintain compliance with all Federal, State, and HIPAA regulations and guidelines.

Requirements

Qualifications

• Background in Inbound or Outbound Customer Service or Financial Services for health plan or healthcare
• Excellent oral and written communication skills
• Proficient in MS Office products (Word, Excel, Outlook)
• Strong listening and problem-solving skills with a patient, customer-focused approach
• Ability to multitask in a fast-paced, metrics-driven environment

Nice to have:

• Experience with Member or Provider phone calls

• Medicaid or Medicaid experience

• Previous medical claims experience (either processing or CSR)

• Knowledge of HIPAA and CMS Guidelines

• Call Center Experience (either inbound or outbound)