CUSTOMER SERVICE AGENT

ESSENTIAL FUNCTIONS

The key responsibilities outlined below represent critical components of this position. Duties may be modified, updated, or reassigned at the discretion of management to meet evolving business needs.
• Processes a high volume of service authorization requests received via fax, phone, and online portals. This includes verifying member eligibility and benefits, documenting relevant clinical and administrative information (e.g., requested services or prescriptions, provider notes, and patient medical history) within the Authorization Tracking System (ATS).
• Forwards authorization requests to Care Management for clinical review and determination, as appropriate. Follows up with providers to obtain missing or additional information based on case requirements.
• Inputs service outcome details as provided by healthcare providers into the ATS.
• Conducts outbound communication with providers, provider office staff, pharmacies, and patients to ensure accurate processing and resolution of requests.
• Responds to a high volume of inbound calls from external customers. Engages professionally and effectively, utilizing call scripts, system information, and subject-matter knowledge to resolve inquiries.
• Maintains a thorough, up-to-date understanding of company policies, procedures, contractual obligations, relevant medical terminology (including infertility-related terminology), systems, and telephone protocols to deliver high-quality support.
• Appropriately escalates calls in accordance with established protocols and guidelines.
• Prepares prescription requests and submits approved prescriptions to partner pharmacies for fulfillment.
• Adheres strictly to HIPAA regulations when handling protected health information.
• Performs additional duties and responsibilities as assigned by management.

MINIMUM QUALIFICATIONS
• High school diploma or equivalent required.
• Minimum of three (3) years of customer service experience in a call center environment, or at least two (2) years of experience in a medical office setting.

KNOWLEDGE, SKILLS AND ABILITIES
• Strong familiarity with medical terminology, as well as CPT and ICD-10 coding; prior experience is highly preferred.
• Working knowledge of HIPAA regulations is beneficial.
• Previous customer service experience within the healthcare or health insurance industry is preferred.

POSITION SUMMARY

The individual in this role is responsible for delivering exceptional service to providers, pharmacies, and patients in alignment with company standards and contractual requirements.

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