The Healthcare Customer Service REP is responsible for resolving benefit and claims inquiries from members and providers via telephone and other approved channels within a call center environment. This role supports a positive customer experience while ensuring compliance with all applicable laws, regulations, and company policies. Responsibilities include:

- Individual contributor role; no direct reports
- Operates in a high-volume call center environment, with the majority of time spent on the phone
- Support External Members, Providers, Brokers, Employers/Groups, Other Insurance Plans, CMS, Social Security Administration
- Handle inbound inquiries related to benefits, claims, billing, and eligibility
- Research and resolve customer issues across multiple systems to ensure accuracy of benefits and payments
- Responding to inquiries regarding adjustments, refunds, and payment discrepancies
- Maintain up-to-date knowledge of policies, procedures, and regulatory requirements
- Document interactions and ensure completeness and accuracy of information
- Meet established customer service performance metrics (quality, productivity, customer satisfaction, attendance)
- Demonstrate ownership of issues and drive First Call Resolution (FCR)

Required Skills

- High School Diploma required
- 1+ year of Healthcare experience in a customer service or medical office environment
- Call center experience is highly preferred
- Strong verbal and written communication skills with professionalism and empathy
- Ability to interpret and explain benefits, claims, and policies clearly
- Critical thinking and problem-solving skills
- Ability to multitask and manage multiple inquiries in a fast-paced environment
- Attention to detail and organizational skills
- Conflict resolution and ability to remain calm under pressure
- Active listening and effective questioning skills
- Proficiency in Microsoft Office and related systems
- Familiarity with healthcare/insurance terminology preferred

Work Environment Expectations
- Approximately 95% of time spent on phone in a call center environment
- May be required to work during emergencies or inclement weather
- Must successfully complete customer service training and demonstrate proficiency