Customer Care Associate I

Job Summary

Job Title: Customer Care Associate I

The Customer Care Specialist is responsible for providing exceptional support to members and providers by addressing inquiries related to eligibility, benefits, claims, and service authorizations. The role involves handling incoming calls, accurately documenting intake information into designated systems, and delivering outstanding customer service to both internal and external stakeholders. The goal is to resolve member and provider needs efficiently, ideally on the first call and consistently meet or exceed established performance standards for quality and productivity.

Responsibilities

• Engage inbound callers professional; actively listen and probe to determine the purpose of the call and resolve administrative concerns, including claims and dissatisfaction
• Make outbound calls to solve member issues (e.g., billing issues with a Pharmacy) or additional information needed for a prior authorization
• Research and communicate member information such as eligibility, benefits, Employee Assistance Program (EAP) services, claims, and authorizations while maintaining confidentiality
• Initiate care programs by accurately assembling and entering patient data into appropriate systems for EAP, Care, and Utilization Management
• Educate providers and members on claims submission, treatment plans, appeal processes, and reimbursement rates across multiple networks
• Identify and respond to crisis calls, assisting clinicians until resolution; make routine referrals and triage decisions not requiring clinical judgment
• Support continuous improvement by identifying operational inefficiencies, performing follow-up tasks, and ensuring member/provider needs are fully met
• Document interactions thoroughly; forward necessary information to appropriate staff and refer provider-related inquiries to the correct teams
• Other duties as assigned

Minimum Qualifications

• High school diploma from an accredited school or GED
• Must be eligible to work in the United States without the need for work visa or residency sponsorship

Additional Qualifications

• Must be flexible in scheduling and comfortable with change
• Must be a proficient typist (avg. 35+ WPM) with strong written and verbal communication skills
• Demonstrated ability to multi-task and maneuver through various computer platforms while verifying information on all calls
• Ability to thrive in high-volume call center environments, managing a large number of inbound and outbound calls efficiently
• Familiarity with medical terminology, healthcare procedures, and insurance-related language to effectively support member and provider inquiries
• Knowledge of HIPAA regulations and other healthcare compliance standards

Preferred Qualifications

• Prior experience in a healthcare or insurance call center environment
• Previous customer service experience
• Previous experience with Genesys and CRM technology platforms