Commercial Health Customer Service Representative

About the Opportunity

The organization is seeking a Commercial Health Customer Service Representative- Remote to serve as a primary point of contact for members and healthcare providers. This full-time, remote position manages inbound and outbound telephone calls and email inquiries, providing accurate and empathetic guidance regarding commercial health plan benefits, eligibility, claims, and billing.

Key Responsibilities

• Research, review, and resolve inbound and outbound member and provider inquiries covering benefits, eligibility, claims, and billing, aiming for first-contact resolution.
• Maintain established department performance metrics and turnaround times, including quality, average handle time (AHT), average speed of answer (ASA), and schedule adherence.
• Explain plan benefits, eligibility, cost-sharing, and claims payment decisions using working knowledge of CPT, ICD-10, HCPCS, and Revenue Codes.
• Deliver provider support regarding claim status, prior authorization requirements, and payment details, as well as handling pharmacy and wellness vendor inquiries.
• Manage initial intake and thorough documentation of escalated member and provider issues.
• Partner cross-functionally with Claims, Medical Management, and other internal teams to resolve complex cases.
• Accurately document all member and provider interactions within the designated customer relationship management (CRM) system.
• Monitor call and inquiry patterns to surface trends to leadership, while assisting members with web portal navigation and digital self-service tools.

Required Qualifications

• High school diploma or equivalent.
• 2+ years of customer service experience supporting commercial fully insured health plan business (experience limited solely to Medicare, Medicaid, or Pharmacy does not qualify).
• Working knowledge of commercial health plan benefits, eligibility, and claims processes.
• Demonstrated knowledge of CPT, ICD-10, HCPCS, and Revenue Codes.
• Proficiency with Microsoft 365.
• Residence and work location within the United States in either the Central or Eastern time zone, with availability during business hours of Monday through Friday, 9:00 AM to 5:00 PM CST.
• Dedicated, private home workspace separate from living areas to ensure information privacy and sensitive document security.
• Existing high-speed internet connection.

Preferred Qualifications

• Associate or bachelor’s degree in business, healthcare, or a related field.
• Experience supporting Claims, Medical Management, or Appeals and Grievances functions.
• Proficiency with Salesforce or a comparable CRM system.
• Experience identifying and reporting call trends, or serving in an informal team lead or quality assurance capacity.

Compensation and Benefits

• Annual base salary of $55,000.
• Health, dental, vision, life, and disability coverage.
• Retirement savings plan with employer match.
• Paid time off.
• Professional development opportunities.