Healthcare Customer Service Representative

Healthcare Customer Service Representative

The Healthcare Customer Service REP is responsible for resolving benefit and claims inquiries from members and providers via telephone and other approved channels within a call center environment. This role supports a positive customer experience while ensuring compliance with all applicable laws, regulations, and company policies. Responsibilities include:

- Individual contributor role; no direct reports
- Operates in a high-volume call center environment, with the majority of time spent on the phone
- Support External Members, Providers, Brokers, Employers/Groups, Other Insurance Plans, CMS, Social Security Administration
- Handle inbound inquiries related to benefits, claims, billing, and eligibility
- Research and resolve customer issues across multiple systems to ensure accuracy of benefits and payments
- Responding to inquiries regarding adjustments, refunds, and payment discrepancies
- Maintain up-to-date knowledge of policies, procedures, and regulatory requirements
- Document interactions and ensure completeness and accuracy of information
- Meet established customer service performance metrics (quality, productivity, customer satisfaction, attendance)
- Demonstrate ownership of issues and drive First Call Resolution (FCR)

Required Skills

- High School Diploma required
- 1+ year of Healthcare experience in a customer service or medical office environment
- Call center experience is highly preferred
- Strong verbal and written communication skills with professionalism and empathy
- Ability to interpret and explain benefits, claims, and policies clearly
- Critical thinking and problem-solving skills
- Ability to multitask and manage multiple inquiries in a fast-paced environment
- Attention to detail and organizational skills
- Conflict resolution and ability to remain calm under pressure
- Active listening and effective questioning skills
- Proficiency in Microsoft Office and related systems
- Familiarity with healthcare/insurance terminology preferred

Work Environment Expectations
- Approximately 95% of time spent on phone in a call center environment
- May be required to work during emergencies or inclement weather
- Must successfully complete customer service training and demonstrate proficiency

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