Overview
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