Customer Service Representative

Job Summary:

Reports directly to the Customer Service Lead and responsible for receiving, documenting, researching, and responding to member inquiries, complaints, appeals and/or grievances. Gathers and presents all relevant data of cases for medical review and makes recommendations for resolution and/or determination of next step. Also responsible for coordinating problem resolution for members, providers, and employer groups amongst various internal departments and external resources/contacts. Responsible for accurate and timely entry of claims data, as well as following regulatory and internal guidelines in conjunction with TakeCare policies and procedures as they apply to claims receipt and adjudication.  Will accurately enter data from the medical and dental claim forms, audit and validate the accuracy of the claims data from the scanned batches.  This position has analytical and/or administrative responsibilities specific to the functional area to which it is assigned. 

Duties and Responsibilities:

1. Customer Service Functions

1.1 Receives, documents, researches, and responds to member inquiries, complaints, appeals and/or grievances.

1.2 Prepares and/or initiates a variety of correspondences/documents in response to inquiries, complaints, appeals and/or grievances.

1.3 Gathers and presents all relevant data of cases for medical review and makes recommendations for resolution and/or determination of next step.

1.4 Coordinates problem resolution for members, providers, and employer groups amongst various internal departments and external resources/contacts.

1.5 Authorizes payment of claims within pre-established limits or guidelines.

 1.6 Educates federal members on benefits, use of plan, premiums and status of claims or appeals/grievances.

 1.7 May contact providers to notify them of overturned appeals and changes of financial responsibility.

1.8 Acts as designated department resource with extensive knowledge of products and provides guidance to other staff members.

1.9 Accumulates and collects updated member demographics.

1.10 Acts as operator as well as messaging entity.

1.11 Performs other duties that may be assigned from time to time.

2.   Quality Review

2.1  Maintain quality and productivity standards as set by management. 

2.2  Alert supervisor of any issues that impact production and quality.

2.3  Ensure all Protected Healthcare Information (PHI) is secured.

Job Specifications:

1. Open to hybrid work arrangement.


2. Graduate of Bachelor's Degree.


3. Minimum of 2 years experience in receiving, documenting, researching and responding to member inquiries, complaints, appeals and/or grievances. Gathers and presents all relevant data of cases for medical review and makes recommendations for resolution and/or determination of next step. Also responsible for coordinating problem resolution for members, providers, and employer groups amongst various internal departments and external resources/contacts.  Knowledge of medical terminology ICD-9; CPT; HCPCS; Revenue Codes and ADA Codes. Call Center experiences a plus.


4. Able to work any shifts including graveyard.


5. Use 10-key by touch. 


6. Effective team player


7. Excellent interpersonal relationship skills and can work and relate well with co-employees, patients, and customers.


8. Must have behavioral sensitivity, maturity, diplomacy, and tact in addressing complex situations and handling irate customers.


9. Outstanding oral and written communication skills.


10. Strong ethics and a high level of personal and professional integrity.


11. Must have basic familiarity with federal and state laws and requirements relating to healthcare management.


12. Computer Proficiency, including experience with Word, Excel, database and e-mail systems.