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Customer Service Representative

Job Introduction

Evaluates preauthorization requests from providers and customers. Deliver personalized service and provide support to brokers, providers and policy holders. Identifies and resolves member claims and customer questions, concerns or complaints with a sense of urgency in order to ensure customer satisfaction.

Role Responsibility

  • Manage claim requests, notification and preauthorization questions via phone and email from members and providers within given deadlines and service objectives.
  • Sends letter of authorization or denial and explanation of benefits depending on the treatment evaluation.
  • Enters notes for every conversation, email and decision in the system so that it is available Companywide.
  •  Handles calls and emails from Business Partner’s,  Brokers, Members and Service Centers  within department expectations to meet company service objectives
  • Resolves questions and issues concerning delays in new business applications, requests.
  • Delivers personalized customer care to brokers and Policy holders by resolving issues personally, regardless of the question or issue, calls back with information or resolution within set deadlines, exceeding customer expectations.
  • Handles questions or claims issues for policies.
  • Able to identify an incorrectly processed claim (i.e. incorrect case handling, payments and diagnosis) and able to cross reference claims among systems.
  • May receives visits from Policy holders visiting Miami.
  • Supports the call center staff in order to meet customer service Key Performance Indicators.
  • Documents all communication in the system to ensure access for everyone.
  • Handles request for proof of insurance.
  • Performs other related tasks as assigned.

The Ideal Candidate

  • College degree 4 years or equivalent in healthcare or business administration with relevant experience preferred.
  • 2-3 years insurance or health care and/or claims experience preferred
  • 1-2 years call center experience preferred.
  • Significant customer service experience 3-4 years required
  • Experience in handling high-end “niche” customers to ensure high level degree of customer service satisfaction.
  • Bilingual English and Spanish fluently read and write with excellent verbal communication skills in both languages Required.
  • Experience with Medical terminology billing and coding preferred
  • Sound knowledge of MS Office software
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