Commercial Health Customer Service Representative- Remote

\n Roles and Responsibilities

* Member & Provider Inquiry Resolution: Researches, reviews, and responds to inbound and outbound member and provider inquiries, using knowledge of benefits, eligibility, claims, and billing to resolve issues at first contact when possible. Meets all turnaround times and department metrics, including quality, AHT, ASA, schedule adherence, etc. * Benefits, Eligibility & Claims Explanation: Accurately interprets and explains plan benefits, eligibility, cost-sharing, and claims payment decisions, applying working knowledge of CPT, ICD-10, HCPCS, and Revenue Codes. Provides support to providers which includes claim status, prior authorization requirements, payment details. Supports pharmacy and wellness vendor inquiries. * Escalation: Owns initial intake and documentation of escalated member and provider situations * Cross-Functional Collaboration & Documentation : Collaborates with Claims, Medical Management, and other internal teams to resolve complex issues, and accurately documents every interaction in the designated CRM system. * Trend Recognition & Member Portal Support: Monitors personal call/inquiry patterns to surface trends to leadership and assists members with portal navigation while promoting long-term digital self-sufficiency.

Qualifications Required

* High school diploma or equivalent required * 2+ years of customer service experience supporting commercial fully insured health plan business * Working knowledge of commercial health plan benefits, eligibility & claims processes * Demonstrated knowledge of CPT, ICD-10, HCPCS & Revenue Codes; Microsoft 365 proficiency required

Pereferred

* Associate's or Bachelor's degree in business, healthcare, or related field * Experience supporting Claims, Medical Management, and/or Appeals and Grievance functions * Proficiency with Salesforce or a comparable CRM system * Experience identifying/reporting call trends or serving in an informal team lead/quality capacity

Telecommuting Requirements

* This is a remote position. Our whole company works remotely. Company headquarters are in Dallas, Texas. * Company business hours are weekdays 9-5 CST. We will only consider candidates in the United States who reside in the CST or EST time zones. * Required to have a dedicated work area established that is separate from other living areas and provides information privacy. * Ability to keep all company sensitive documents secure. * Must live in a location that receives an existing high-speed internet connection/service.

Benefits Package

* Competitive salary * Comprehensive health, dental, and vision insurance as well as life and disability * Retirement savings plan with company match * Generous time off/vacation * Professional development opportunities * Flexible and remote work environment

\n $55,000 - $55,000 a year \n