Customer Service Representative

Customer Service Role

Under the general direction of the Customer Service Director, this position is responsible for responding to suggestions, inquiries and complaints/grievances from members and providers regarding claim status, claim payments, eligibility/enrollment, plan benefits, referrals, etc. and ensuring timely resolution.

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Essential Duties:

  • Manage inquiries from members and providers regarding claim status, claim payments, eligibility/enrollment, plan benefits, billing and referrals according to departmental procedures.
  • Log all calls, voicemails and other inquiries received into Call Diary.
  • Report consumer complaints/grievances and the resolution of complaints/grievances.
  • Monitor inquiries forwarded to other departments for timely resolutions of issues. Provide follow-up as necessary.
  • Participate in departmental rotations for staffing the extended-hour Medicare phone on a regular basis and during open enrollment; working mail; retrieving and returning voicemails; and managing open call reports.
  • Participate in ongoing training and departmental staff meetings.
  • Help handle IT issues in regards to the Member Portal
  • Participate in cross training in other departments as needed
  • Assist the Billing Department by taking member premium payments
  • Participate in second interview process with new Customer Service Rep hires
  • Perform other duties as assigned.

Required Knowledge, Skills & Abilities:

  • Detail oriented
  • Highly organized
  • Ability to exercise good judgment
  • Excellent interpersonal skills
  • Ability to understand and interpret policies and procedures
  • Good oral communication skills
  • Professionalism in dealing with coworkers, members and providers
  • Excellent phone skills
  • Ability to work under pressure
  • Must be personable, empathetic, but firm in dealing with members and providers
  • Resourceful in solving problems, researching issues and communicating with members, providers and coworkers.

Required Education/Experience:

  • High school diploma or GED required
  • Basic knowledge of computers and other office equipment

Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is occasionally required to stand; walk; sit; use hands to finger, handle, or feel objects, tools or controls; reach with hands and arms; climb stairs; balance; stoop, kneel, crouch or crawl; talk or hear; taste or smell. The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.

Other Duties:

Note that this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

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