Commercial Health Customer Service Representative

**Roles and

responsibilities:/strong>**

• 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:/strong>**

• 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