Your Role
Our Designated Customer Experience Teams receive incoming telephone calls from Self-Funded Large Group Commercial Plans. The Designated Call Center is open Monday - Friday, 4:45 a.m. – 8:00 p.m., including some holidays. If hired, you will be required to attend and complete paid, mandatory training remotely. You must attend each day for 8 hours, totaling 40 hours per week for the required training period. Training hours are 8:00 a.m-4:30.p.m Mon-Fri. After completion of successful training the agent may continue to work remotely in accordance with our work from home policy and will be assigned a 40-hour shift/schedule between the hours of 4:45 a.m. – 8:00 p.m. Monday - Friday.
The following job summary will help you understand the candidates/people well suited to our Designated Call Center Team.
Job Summary:
Projected Start date: October 2026
Mandatory Training: Remote
As a Designated Customer Service Representative (CSR), you are in charge of upholding our mission of providing a service worthy of our family and friends. Our members look to you to help them navigate healthcare, providing empathy and advocacy. You are empowered to provide members with peace of mind that their current issue is resolved and that none are on the horizon. Designated provides health coverage to Self-Funded Large Group Commercial Plans.
Successful CSRs deliver an effortless customer experience by:
Taking the lead – our CSRs take ownership of members' issues, relieving members' stress while guiding them to a quick and easy resolution.
Identifying future problems – not only do our CSRs solve the current member concern but they actively identify and solve any lurking complications the member may encounter after their first interaction.
Sharing insights with peers and management – our positive team culture relies on open communication to continuously improve how our work gets done.
Having fun! – our work is important, but we don't take ourselves too seriously. We love helping others and have a fun community dedicated to doing so!
You must also be:
Available to work a scheduled 8-hour shift, which includes 2 scheduled breaks and a lunch period, also available to work occasional holidays as part of your regularly scheduled shift
Patient with members who call into our Centers with a question or a problem
A good listener and not only answer the questions they ask you, but identify and answer questions the member may not be aware they needed
Comfortable using a computer with 2 display monitors to allow you to navigate to multiple screens for information
Comfortable using Excel spreadsheets to calculate member premiums for health insurance
To multi-task using a computer; talking to the member, and entering member information into their online record
Your Work
In this role, you will:
Resolve incoming calls concerning member's eligibility, benefits, provider information, clinical and pharmacy needs
Compose routine and non-routine correspondence to answer benefits/provider inquiries in writing
Coordinate membership changes such as member's primary care physician
Perform routine to mid-level inventory reduction (i.e., member inquiries, may initiate claim adjustments, respond to emails, etc.)
Review and analyze member claims for accuracy as well as member education on how benefits are applied
Participate in quality and efficiency workgroups to continuously improve quality member/customer satisfaction as requested
Proactively analyze available programs, determine program eligibility and connect the Member to appropriate BSC vendors, Health Advocates, Social Workers, Pharmacy Techs, and Pharmacists. Verify the member is included in or targeted for any outreach or care gap programs and connect members to programs or services when appropriate. Engage members with their wellness plan options
Comprehensive resolution of pharmacy calls concerning benefits coverage, co-pays, formulary coverage, vacation overrides, and utilization management requirements
Provide prescription-related benefit coverage (e.g. explanation of coverage or benefit summary related): Provide prescription co-pays. Provide prescription formulary coverage information and utilization management requirements using web-posted printed formulary. Provide a brief description of coverage denial reasons and alternatives listed in the printed formulary. Perform prescription claim overrides
Provide deductible and max out of pocket information
Provide status of prior authorization requests
Assist members may when and how to appeal a coverage decision
Other duties as assigned
Your Knowledge and Experience
Preferred Qualifications
Bilingual – Spanish. Language proficiency as demonstrated by successful completion of an oral language proficiency test
Hybrid Virtual Work
This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.
