Health Insurance Customer Service Representative

Job Description

Job Description

Under 65 Health Claims Customer Service Representative (CSR)

Location: Main Office

Schedule: Monday–Friday, 8:00 a.m. – 5:00 p.m.

Job Type: Full-time | Status: Non-Exempt

Position Summary

The Under 65 Claims Customer Service Representative (CSR) is the first point of contact for members, providers, and agents, providing exceptional support related to health claims, benefits, and policy information. This role ensures timely, accurate, and compassionate service while helping customers navigate complex healthcare coverage. The ideal candidate demonstrates empathy, professionalism, and a strong commitment to improving the customer experience.

Key Responsibilities

Respond to inquiries from members, providers, and agents regarding claims, benefits, authorizations, and account details.

Deliver clear, accurate, and empathetic communication across all interactions.

Navigate internal systems efficiently to access and share relevant information.

Escalate complex or system-related issues to supervisors or specialized teams.

Explain policy details, coverage options, eligibility, limitations, and exclusions.

Guide customers through claims submissions, appeals, and self-service tools.

Investigate and resolve claim denials, benefit disputes, and billing discrepancies.

Apply critical thinking and active listening to identify issues and propose solutions.

Balance customer needs with company policies to ensure fair, compliant resolutions.

Accurately document all interactions and maintain up-to-date records in company systems.

Follow call center performance standards, including handling time, compliance, and quality metrics.

Stay informed on policy updates, regulatory changes, and company procedures.

Ensure strict compliance with HIPAA and confidentiality requirements.

Participate in ongoing training, coaching, and performance reviews.

Collaborate with trainers, auditors, and leadership to improve quality and efficiency.

Provide customer insights and feedback to support process improvement initiatives.

Qualifications

Required:

Excellent verbal and written communication skills, with strong empathy and active listening abilities.

Professional demeanor with the ability to remain calm under pressure.

Strong multitasking, problem-solving, and time management skills.

Dependable, adaptable, and team-oriented attitude.

Proficiency in Microsoft Outlook, Teams, and Word.

Legal authorization to work in the U.S.

Preferred:

1–3+ years of customer service or call center experience, ideally within the health insurance industry.

Education

High school diploma or equivalent required.

Work Environment

Professional office environment with standard hours (Monday–Friday, 8am–5pm).

Occasional extended hours during peak periods.

Frequent use of computers, phones, and standard office equipment.

Regular interaction with staff, leadership, and customers in a fast-paced setting.

Occasional lifting of up to 15 pounds (e.g., office supplies or equipment).

Hybrid or remote work options may be available based on business needs and company policy.

Company Benefits

Competitive salary with performance-based incentives

Comprehensive medical, dental, and vision insurance

Flexible Spending Account (FSA)

Company-paid life and disability insurance

401(k) with company match

Paid time off (vacation, sick leave, and holidays)

Employee wellness programs and resources

Supportive, collaborative work environment

Join our team and help make a difference in the lives of our members—one call at a time.