Commercial Health Customer Service Representative

Roles and responsibilities

• Research, review, and respond to inbound and outbound member and provider inquiries (benefits, eligibility, claims, billing); resolve at first contact
• Meet turnaround, quality, AHT, ASA, and schedule metrics
• Interpret and explain plan benefits, eligibility, cost-sharing, and claims decisions using CPT, ICD-10, HCPCS, and Revenue Codes
• Support providers (claim status, prior auth, payment details, pharmacy and wellness vendors)
• Own intake and documentation of escalations
• Collaborate with Claims and Medical Management
• Document in CRM
• Monitor call and inquiry patterns and trends
• Assist members with portal navigation

Qualifications, required

• High school diploma or equivalent
• 2+ years customer service supporting commercial fully insured health plan business
• Working knowledge of commercial health plan benefits, eligibility, and claims
• CPT, ICD-10, HCPCS, Revenue Codes knowledge
• Microsoft 365 proficiency

Qualifications, preferred

• Associate’s or Bachelor’s in business, healthcare, or related field
• Claims, Medical Management, Appeals, or Grievance experience
• Salesforce or comparable CRM
• Trend identification, informal team lead, or quality experience

Telecommuting requirements

• Dedicated separate work area with information privacy required
• High-speed internet required

Benefits package

• Competitive salary
• Comprehensive health, dental, vision plus life and disability
• Retirement plan with match
• Generous time off
• Professional development
• Flexible remote environment

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