Commercial Health Customer Service Representative

Roles and responsibilities 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 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