The CSR position interacts with customers to provide and process information in response to complex inquiries, concerns, and requests about health claims, coverage, benefits, and deductibles. Projects a professional company image and provides superior customer service by corresponding with Providers, Members, internal and external partners to proactively own the experience and resolve coverage issues.

• Thoroughly and completely document all customer interactions.
• Educates Members and Providers on eligibility, benefits, claims payment, and authorizations.
• Provides direction on the usage and benefits of self-service tools.
• Resolve claim benefit inquiries by researching and analyzing patient activity and determine appropriate action to be taken.
• Adjusts claims data, when appropriate, to immediately resolve the inquiry and maintain first call resolution expectations.
• Appropriately route inquiries to the necessary departments or individuals when resolution of the inquiry is beyond the span of control of this role and set follow ups.
• Meet or exceed individual, department, and client specific goals. Assist providers by resolving coordination of benefits inquiries by analyzing patient activity (including enrollment, third party liability, and claims attachments).
• Interpret and communicate accurate insurance coverage by having a comprehensive understanding of the process.
• Meet or exceed individual and department goals.
• Understands and adheres to all of the client's administrative and contractual policies and procedures.
• Takes ownership of the resolution and sets expectations for follow up.
• Able to work a shift which may begin 8 am to 10 pm EST Monday - Friday.

• Prior call center / medical experience helpful
• Must have analytical/problem solving capabilities
• Must be PC literate with 10-key proficient
• Excellent oral and written communication skills