Customer Service Representative

Position SummaryThe Customer Service Member Support Rep serves as the frontline member advocate and primary point of contact for Detego Health members. This role assists members with routine questions regarding eligibility, benefits, claims, billing, provider networks, pharmacy benefits, and available member resources while delivering a professional, empathetic, and member-focused experience.Customer Service Member Support Rep team members work within established procedures, workflows, and service standards to resolve routine inquiries, educate members regarding their coverage, accurately document interactions, and escalate complex or unresolved concerns as appropriate.This is a non-clinical customer service position focused exclusively on health insurance navigation and member advocacy. Customer Service Member Support Reps do not provide medical advice, diagnose medical conditions, recommend treatments, interpret clinical information, or deliver healthcare services.Key Responsibilities· Serve as the first point of contact for member inquiries via telephone, email, and other approved communication channels.· Deliver a positive, professional, empathetic, and member-focused experience during every interaction.· Verify member identity and protect confidential information in accordance with HIPAA and company privacy requirements.· Educate members regarding eligibility, enrollment, benefits, claims, billing, provider networks, pharmacy benefits, prior authorizations, reimbursement programs, and available member resources.· Research and resolve routine member inquiries using approved systems, knowledge bases, and internal resources.· Accurately document all member interactions in Salesforce CRM and other required systems.· Conduct outbound calls for follow-up, education, issue resolution, and member engagement as assigned.· Escalate complex, sensitive, or unresolved issues to appropriate internal resources or higher-level Care Guides.· Meet departmental standards for quality, productivity, average handle time, first call resolution, documentation accuracy, schedule adherence, attendance, and compliance.· Participate in training, coaching, team meetings, and continuous improvement activities.· Perform other related duties as assigned.Employee Acknowledgment and DisclaimerI acknowledge that I have received, reviewed, and understand this Job Description. I understand that this document is intended to describe the general nature, essential functions, responsibilities, qualifications, and expectations of the position.I recognize that this Job Description is not intended to be a comprehensive list of all duties, responsibilities, or qualifications associated with the role. The Company reserves the right to modify, assign, or remove job duties and responsibilities at any time to meet business needs.I understand that this Job Description does not constitute a contract of employment, express or implied, and does not alter the at-will nature of my employment. Employment may be terminated by either the employee or the Company at any time, with or without notice, and with or without cause, subject to applicable law.My signature below acknowledges that I have reviewed and understand the contents of this Job Description and have had the opportunity to ask questions regarding my role and responsibilities.My signature does not certify that I am able to perform every duty listed in this Job Description; rather, it acknowledges my understanding of the position's responsibilities and expectations, which may be performed with or without reasonable accommodation, as applicable.Employee Name: ______________________________________Employee Signature: ___________________________________Date: ________________________________________________QualificationsCustomer Service· Excellent customer service, communication, active listening, conflict resolution, and de-escalation skills.· Ability to build rapport and provide an exceptional member experience.Call Center· Ability to work in a fast-paced, metrics-driven call center environment.· Ability to handle consecutive inbound and outbound calls while balancing efficiency, quality, and accuracy.Technical Skills· Strong computer navigation skills and ability to work across multiple applications and monitors simultaneously.· Strong documentation, data entry, and CRM/case management system skills.· Ability to learn new software systems and internal processes quickly.Health Insurance Knowledge· Understanding of eligibility, enrollment, benefits, claims, provider networks, pharmacy benefits, deductibles, copayments, coinsurance, out-of-pocket maximums, prior authorization, and Explanation of Benefits.· Ability to educate members about benefits without providing medical advice.Critical Thinking· Strong analytical and problem-solving skills.· Sound judgment when handling confidential, sensitive, or escalated member information.Physical Requirements· Ability to remain seated for extended periods.· Frequent computer and headset use.· Frequent keyboarding and viewing multiple monitors.· Occasionally lift up to 15 pounds. #J-18808-Ljbffr Priority Dispatch Corp.