Customer Service Representative

Description

JOB SUMMARY

The Customer Service Representative serves as the front-line point of contact for members, providers, and health plan partners within the MSO. This role responds to inbound calls and written inquiries, provides accurate benefit and eligibility information, supports access to care and provider services needs, documents all interactions in the designated customer service platform, and escalates complex issues in accordance with departmental policies and regulatory and contractual requirements. The Representative supports all lines of business, including Medi-Cal, Medicare Advantage, and Commercial plans, while maintaining service excellence, confidentiality, and compliance. 

Requirements

MINIMUM & PREFERRED QUALIFICATIONS

Education

Minimum: High school diploma or equivalent.
Preferred: Associate’s degree or college coursework in Healthcare Administration, Business, or related field.

Experience 

Minimum: at least one year of customer service, call center, or healthcare administrative experience.
Preferred: Experience in managed care, MSO, IPA, or health plan environment; familiarity with member/provider systems (e.g., EZ-Cap, Salesforce, or comparable CRM).

Skills, Knowledge & Abilities

· Strong customer service and interpersonal skills with a commitment to service excellence.

· Excellent verbal and written communication skills; ability to explain benefit and process information clearly.

· Ability to de-escalate concerns and resolve issues using empathy, professionalism, and sound judgment.

· Strong attention to detail and accuracy in documentation and data entry.

· Ability to navigate multiple systems and applications while on calls; strong computer proficiency.

· Working knowledge of call center practices and performance metrics (AHT, ASA, FCR, service level).

· Familiarity with managed care concepts including eligibility, benefits, authorizations, claims routing, and provider network structure.

· Ability to follow scripts, policies, and workflows and to adapt to benefit or system changes.

· Ability to recognize urgent or complex issues and escalate appropriately per protocol.

· Commitment to confidentiality and compliance with HIPAA and organizational privacy and security policies.

· Strong organizational and time management skills; ability to manage competing priorities and deadlines.

· Ability to work effectively in a team environment and collaborate across departments.

· Customer-focused mindset with the ability to maintain composure in a fast-paced environment.

· Ability to maintain professionalism and confidentiality at all times.

· Experience with customer service platforms (EZ-Cap, Salesforce, CRM systems) preferred.

· Bilingual in English/Spanish skills preferred.

· Ability to learn and apply regulatory and health plan requirements relevant to customer service operations.

PHYSICAL, MENTAL & ENVIRONMENTAL REQUIREMENTS

The physical demands described here are represented by those that must be met by an employee to successfully perform the essential functions of this job. There will be prolonged periods of sitting, working on a computer, and using a telephone/headset. While performing the duties of this job, the employee will regularly be required to walk, stand, bend, lift and/or move up to 15-20 pounds. Ability to work extended hours during peak periods or audit timelines, as needed. Requires visual acuity to review documents, reports, and system data. Specific vision abilities required by this job include close, distance, color, peripheral vision, depth perception and the ability to adjust focus.