Customer Service Representative

**Job Description**:
As a Third-Party Administrator for dozens of Healthcare Insurance companies located
overseas, the Customer Service Representative is responsible to handle Inbound
whose medical services will take place either in the United States or the rest of the
world. Besides providing coverage details to medical Providers/insured Members,
coordinating cashless appointments worldwide, providing bill status information to
Providers, the CSR will work closely with the Case Management department on services
that require an authorization which include identifying services that must be pre-certified
and initiating the pre-authorization process. Last but not least, the CSR will be working
with Account Management for any bill related matters that need to be escalated.

**Main daily responsibilities, but not limited to**:

- Direct communications with Members, Providers, Corporate Clients via phone,
- Register Policies in the system with proper eligibility, add Members/dependents

and create appropriate tasks that will trigger proper workflow
- Documentation of all calls or communications in the Members record (when

applicable)
- Confirmation of Benefits and Eligibility information to members and providers.
- Identify medical services that require an authorization from the Corporate Client

and take appropriate actions (initiate authorization, provide status on existing
ones and escalate any issues to Case Management)
- Coordination of medical services in/outside the USA, this, in most cases, include

locating and contacting several Providers who have the availability and suit the
Members preferences and accept our Guarantee of Payment for a cashless
experience
- Ensure that Providers send claims to the proper address for processing and/or

payment and that only the correct amounts are collected from the patient
(deductible, co-payments, etc.) Assignment of benefits
- Provide referrals to in network Providers to all Members, Corporate Clients and

sometime other Providers, confirmation of participation of a specific Provider in
the network. Steer callers to in network facilities/providers to generate higher
revenue.
- Provide claims information like status, process date, detailed payment amount,

check number, discounts taken, etc. to Members, Corporate Clients and
Providers by making the necessary contacts.
- Assist on resolving any billing issue by contacting the appropriate department

and/or parties involved.
- Identify balance billing by analyzing claim and payment information available.
- Identify potential problems and take prompt corrective actions in order to avoid

escalated issues that require supervisory intervention.
- Keep Account Managers informed of any delicate issue that may require their

attention in order to avoid or resolve an existing problem.
- Calm irate Members and Providers and reassure their problems and concerns

will be dealt with in an effective and timely manner.

being dealt with. Multitask and prioritize
- Make decisions on when a specific issue needs to be brought to the attention of

the supervisor/manager.
- Respond and address new business concerns from existing and potential

customers.
- Log and record all type communications for patient files.
- Respond to general queries from members (policy procedures, reimbursements,

etc.). Redirect callers when necessary
- Follow up until completion on all issues that are not resolved on the initial

contact, keep parties updated on steps and actions taken.
- Service the maximum amount of callers in the quickest and most efficient way

without sacrificing the quality of the service.

**Requirements**:

- Bilingual (English & Spanish)
- Must be detail-oriented and organized
- Must possess critical thinking skills as well as the ability to manage time
efficiently.
- Must be able to gather the information necessary to assist customers.
- Always be sharp and alert.
- Needs to communicate well with co-workers (verbal and written).
- Knowledge of phone manners, etiquette and protocols.
- Professional phone etiquette and written skills
- Ability to adapt to changes
- Able to understand, interpret and explain policies and procedures as well as
knowledge of commonly used concepts, practices and procedures in the field.
- Ability to deal with irate customers and complaints while maintaining composure
and control of the situation.
- Knowledge of Microsoft Office.
- Ability to learn from past experiences