Customer Service Representative I

Under the direction of the Supervisor, Customer Service, this position is responsible for meeting KPIs while responding to general customer inquiries regarding insurance benefits, provider contracts, reimbursement programs, eligibility, and claims from members, providers and employers in a confidential, professional, and ethical manner. The incumbent will also research and analyze data to address standard operational challenges and issues within the Customer Service department.

Duties And Responsibilities

Customer Advocate

• Respond to general customer questions via telephone, e-mail, and written correspondence regarding insurance benefits, provider contracts, reimbursement programs, eligibility, and claims in a confidential, professional, and ethical manner.
• Analyze problems and provide information/solutions.
• Research and resolve aged Customer Service open calls within company standards.
• Operate in the Health Care Processing System (HCPS), Imaging systems, and all systems necessary to obtain and extract information with proficiency and skills.
• Develop and maintain positive customer relations and coordinate with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner.
• Be accountable when you uncover an issue or trend by helping to assess and report its impact, making improvements, and course-correcting along the way.
• Follow quality guidelines to provide exceptional customer support and ensure scores meet or exceed expectations.

• Accurately document database activity and customer interaction for tracking and analysis to identify trends and address operational and service issues.
• Research and analyze data to address standard operational challenges and customer service issues.
• Provide customers with requested information, including difficult and upset customers.
• Meet or exceed all department and performance service metrics.
• Communicate with the appropriate departments and identify service issues.
• Identify inefficiencies within the established processes and suggest possible solutions to save time, reduce risk, and/or reduce expenses.

• Maintain regular attendance per employee handbook guidelines.
• Utilize all capabilities to satisfy one mission — to enhance the competitiveness and profitability of our members. Do everything possible to help members succeed by being curious and striving to understand what others are trying to achieve, planning, and executing work helpfully and collaboratively. Be willing to adjust efforts to ensure that work and attitude are helpful to others, be self-accountable, create a positive impact, and be diligent in delivering results.
• Maintain internet speed of 40 MB download and 10 MB upload and router with wired Ethernet.
• Maintain a HIPAA-compliant workstation and utilize appropriate security techniques to ensure HIPAA-required protection of all confidential/protected client data.
• Maintain and service safety equipment (e.g., smoke detector, fire extinguisher, first aid kit).
• All other duties as assigned.

The physical demands and work environment described here represent those that an employee must meet to successfully perform this job’s essential functions. 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 regularly required to communicate with others. The employee frequently is required to move around the office. The employee is often required to use tools, objects, and controls. This noise level in the work environment is usually moderate.