Customer Service Specialist

Position Summary

Customer Service Specialist is responsible for providing support to network providers, medical offices and billing companies.  The customer service specialist will answer questions regarding eligibility, authorization, network guidelines, claims status and general health plan information.

Duties and Responsibilities

  • Answer calls, from providers for eligibility and claim status.
  • Search for members through QuickCap and main health plan sites in order to check on eligibility.
  • Read paid and denied claims and explain denial codes.
  • Educates providers on the appeal/claim submission process and provider portal use.
  • Demonstrates professional etiquette and courtesy when interfacing with providers.
  • Documents accurately and comprehensively based on organization policies and procedures through investigative research to create internal PDR’s.
  • Assist the Claim Department by entering appeals in QuickCap.
  • Assist the health plan by providing participating physician information within the network per LOB.
  • Assist the other customer service representatives on escalated issues.
  • Performs other duties as assigned by Management.


  • Specialty network experience in claims and customer service is preferred
  • 3+ years of experience in the healthcare industry


  • Fluency in English and Spanish; oral and written communication
  • Microsoft (Outlook, Excel, Word, and PowerPoint)
  • Data Entry
  • Sales Skills


  • Ability to work with patience and courtesy in customer service.
  • Ability to communicate effectively, both verbally and in writing.
  • Ability to think quickly and logically to ensure appropriate response to provider inquiries and be able to enter information into multiple screens while listening to information from providers.
  • Must have strong organizational skills.

Physical Demands

The physical demands described here are representative of those that must be met by the employee to successfully perform the essential functions of this job.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle or feel; reach with hands and arms and talk and hear.  The employee is occasionally required to stand; walk and stoop, kneel or crouch.  Specific vision abilities required by this job include close vision and ability to adjust focus.

Position Type/ Expected Hours of Work

This is a full time position.  Days and hours of work are Monday through Friday 8:00 a.m. to 5:00 p.m. Occasional evening and weekend work may be required as job duties demand.

Work Environment

This job operates in a clerical office setting.  This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines.  The work environment characteristics described here are representative of those encountered while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.


This position requires less than 5% travel

Other Duties

Please note this job description is not designated to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job.  Duties, responsibilities and activities may change at any time with or without notice.

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