This is a fully remote position, open to applicants in United States.

📋 Description

• Conduct research, review, and respond to both incoming and outgoing inquiries from members and providers.

• Address issues related to benefits, eligibility, claims, and billing during the first contact whenever feasible.

• Achieve turnaround times and meet departmental metrics, including quality, Average Handle Time (AHT), Average Speed of Answer (ASA), and adherence to schedule.

• Interpret and clarify plan benefits, eligibility criteria, cost-sharing, and decisions regarding claims payments.

• Assist providers with inquiries about claim status, prior authorization requirements, and payment information.

• Provide support for pharmacy and wellness vendor inquiries.

• Manage the initial intake and documentation of escalated member and provider issues.

• Collaborate with Claims, Medical Management, and other internal teams to resolve intricate issues.

• Record every interaction in the specified CRM system.

• Analyze call and inquiry patterns to identify trends for leadership's attention.

• Guide members in navigating the portal and encourage digital self-sufficiency.

⛳️ Requirements

• A high school diploma or equivalent is mandatory.

• At least 2 years of experience in customer service supporting commercial fully insured health plan operations.

• Familiarity with commercial health plan benefits, eligibility, and claims processes is essential.

• Proven knowledge of CPT, ICD-10, HCPCS, and Revenue Codes is required.

• Proficiency in Microsoft 365 is necessary.

• Bilingual fluency in English and Spanish is required.

• Must reside in or work from the United States, specifically within the CST or EST time zone.

• A dedicated workspace separate from living areas that ensures information privacy is required.

• Ability to maintain the security of sensitive company documents is essential.

• Must have access to a location with reliable high-speed internet service.

🏝️ Benefits

• Comprehensive health, dental, and vision insurance.

• Life and disability insurance coverage.

• Retirement savings plan featuring a company match.

• Generous paid time off and vacation policies.

• Opportunities for professional development.

• Flexible and remote work environment.