- Research and resolve inbound and outbound member and provider inquiries regarding benefits, eligibility, claims, and billing.
- Meet department metrics including quality, AHT, ASA, and schedule adherence.
- Interpret and explain plan benefits, cost-sharing, and claims payment decisions using CPT, ICD-10, HCPCS, and Revenue Codes.
- Support providers with claim status, prior authorization requirements, and payment details.
- Document escalated situations and interaction details in the company CRM.
- Collaborate cross-functionally with Claims and Medical Management teams to resolve complex issues.
- Assist members with portal navigation and identify recurring call trends for leadership.
Customer serviceCRM