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 gudelines, claims status and general health plan information.

Duties and Responsibilities

•Answer calls, from providers to verify eligibility and provide them with claims payment status.

•Search for members navigating through the TPA System and main health plan sites in order to check on member eligibility.

•Read and comprehend paid and denied claims and explain denial codes.

•Educate providers on the appeal/claim submission process and provider portal use.

•Demonstrate professional etiquette and courtesy when interacting with providers.

•Accurately and comprehensively documents all communications from providers based on organization policies and procedures through investigative research to create internal PDR’s. internal open tickets.

•Assist the Claim Department by entering appeals in the TPA System.

•Assist the health plan by providing participating physicians information within the network per line of business(LOB).

•Assist the other customer service representatives on escalated issues.

•Support coverage for mailroom

•Support coverage for EDI Specialist

•Process daily pending eligibility review for claims department workflow .

•Generate provider letter weekly for rejected claim.

•Generate and mail daily NABD & NDP letters.

•Create refund letters and upload supporting documents in the claims processing system

•Review deductibles and out of pockets accumulators’ queue for claims department

•Distribute faxes that are received daily to all departments.

•Performs other duties as assigned by Management.


•Specialty Network experience in Claims and/or Customer Service is preferred.

•Minimum of three (3) years of experience in the Healthcare industry.


•Fluent in English and Spanish; oral and written communication.

•Microsoft (Outlook, Excel, Work, and PowerPoint).

•Accurate Data Entry.

•Sales Skills.


•Ability to work with patience and courtesy while attending Providers and Health Plan partners.

•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.

•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 general time span: 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 10% 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.