In these joint roles as a Customer Service and Claims Representative, you’ll join us on a mission to not only deliver the best customer service. Period. Your compassion and customer service expertise combined with our support, training and development will ensure your success. 

In this role, you play a critical role in creating a quality experience for the callers that you connect with and those that you correspond with. Every interaction gives you that opportunity to improve the lives of our customers and exceed their expectations. You’ll spend the majority of your day by responding to chats and calls from our members and help answer questions and resolve issues regarding eligibility, claims and payments. You’ll also spend a portion of your time reviewing, researching and processing claims with the goal to ensure that every claim has a fair and thorough review.

These positions are full-time (40 hours/week) Monday – Friday. Employees are required to have flexibility to work any of our 8 hour shift schedules during our normal business hours of (7am – 9pm) in your time zone. It may be necessary, given the business need, to work occasional overtime or weekends. This will be a work at home / telecommute role after training, which will be conducted onsite in one of our satellite offices nationwide.  

Primary Responsibilities: 

• Answer incoming phone calls from customers and identify the type of assistance the customer needs (i.e. benefit and eligibility, billing and payments, authorizations for treatment and explanation of benefits (EOBs)

• Ask appropriate questions and listen actively to identify specific questions or issues while documenting required information in computer systems

• Own problem through to resolution on behalf of the customer in real time or through comprehensive and timely follow-up with the member

• Review and research incoming healthcare claims from members and providers(doctors, clinics, etc) by navigating multiple computer systems and platforms and verifies the data/information necessary for processing (e.g. pricing, prior authorizations, applicable benefits)

• Ensure that the proper benefits are applied to each claim by using the appropriate processes and procedures (e.g. claims processing policies and procedures, grievance procedures, state mandates, CMS/Medicare guidelines, benefit plan  documents/certificates)

• Communicate and collaborate with members and providers to resolve issues, using clear, simple language to ensure understanding