Job Summary:
As a Customer Service Specialist, you will play a pivotal role in enhancing customer satisfaction and business productivity. Reporting directly to the Customer Service Supervisor, you will be responsible for receiving, documenting, and resolving escalated member inquiries, complaints, appeals, and grievances. You will gather and present all relevant data of case for medical review and will make recommendations for resolution and/or determination of next step. Also responsible for coordinating problem resolution for members, providers, and employer groups
amongst various internal departments and external resources/contacts.

Essential Duties and Responsibilities:
• Serve as liaison between customer service team, management and customer to improve customer service and business productivity.
• Analyze customer complaints and provide appropriate corrective actions.
• Assist in training peers on improving customer service.
• Receives, documents, researches and responds to member inquiries, complaints, appeals, and grievances from callers and visitors.
• Prepares and/or initiates a variety of correspondence/documents in response to inquiries, complaints, appeals and grievances.
• Gathers and presents all relevant data of case for medical review and makes recommendations for resolution and/or determination of next step.
• Coordinates problem resolution for members, providers, and employer groups amongst various internal departments and external resources/contacts.
• Authorizes payment of claims within pre-establish limits or guidelines.
• Educates members on benefits, use of plan, premiums and status of claims, appeals, and grievances.
• May contact providers to notify them of overturned appeals and changes of financial responsibility.
• Handles primary duties of the Coordinator, when necessary.
• Acts as designated department resource with extensive knowledge of simple matters and provides guidance to other staff members.
• Accumulates and collects updated member demographics.
• May be assigned special project, such as Grievance Coordinator/Appeal Coordinator. Responsible for receiving and documenting all written grievances/appeals and for facilitating
timely review and responses from respective parties.
• Performs other duties that may be assigned from time to time.

Education & Experience:
1. High school diploma or equivalent.
2. 1 year experience in Customer Support.
3.  Healthcare experience and/or clinic administration preferred but not required.
4.  Must have the behavioral sensitivity, maturity, diplomacy and tact in addressing complex situations and handling irate customers.
5.  Exceptional customer service skills including effective and efficient problem solving and analyzing skills.
6.  Ability to perform essential job functions with high degree of independence, flexibility, and creative problem solving techniques.
7.  Ability to effectively handle and prioritize multiple tasks, frequent interruptions and details with accuracy.
8. Must have strong organizational skills.
9. Outstanding oral and written communication skills.
10. Skill with interpersonal relationships and ability to effectively interact with all levels of  staff and outside contacts.
11. Strong ethics and a high level of personal and professional integrity.
12. Must have basic familiarity on federal and state laws and requirements relating to healthcare management.
13. Computer-literate and very highly proficient in using MS office programs.