Job Description

Monterey, CA

Full Time

Work Hours: M-F 8-5


Customer Service Representative


Position Highlights

·         Excellent Pay and Generous Benefits

·         Team Oriented Culture

·         Excellent work environment!


Position Summary


The Customer Service Representative is responsible for answering telephone inquiries and responding to correspondence from employer clients, members and providers regarding eligibility, claims status and benefit determinations.



  • Intake all customer (provider, member and health plan) calls as they relate to inquiries and grievances.
  • Explain health insurance benefits, policies and procedures to members and providers, i.e., claims submission, appeal process, medical review, documenting all communication.
  • Investigate timely filing of provider claims.
  • Serve as a point of contact and liaison for customers.
  • Successfully implement dispute resolution.
  • Provide proactive and event-related education to customers.
  • Facilitate customer care as appropriate.
  • Assure accurate and timely response to all customer inquiries.
  • Log calls and document action plans.
  • Successfully bring all issues to closure within appropriate timeframe.
  • Proactively identify areas of improvement and provide feedback.
  • Perform member and provider satisfaction surveys as appropriate.
  • Provide support and coverage to interdepartmental staff as needed.
  • Coordinate customer grievances with appropriate department.
  • Develop strong partner relationship with customers.
  • Perform other activities and functions as defined by the Claims Manager.


Experience/Skill Set required:

·         Minimum two years' experience in customer service/call center within the managed care, insurance, healthcare, or related call center environment

·         Strong comprehension skills

·         Ability to communicate effectively, including written and verbal communication skills

·         Attention to details in obtaining complete and accurate information

·          Problem resolution skills

·         Strong interpersonal and negotiation skills

·         Ability to key data accurately and rapidly

·         Basic knowledge of insurance terminology and medical coding, e.g. ICD and CPT

·         Ability to operate computer equipment and software programs necessary to fulfill position responsibilities

·         Working knowledge of Microsoft office products including Outlook, Word, and Excel

·          Ability to interact professionally with co-workers, providers, clients, brokers and management-level staff.

·         Excellent phone manner and ability to handle multiple phone lines.

·         Must be able to meet established deadlines



·         Minimum A.A. degree or equivalent practical experience in related or similar positions.


Equal Opportunity Employer

Application Instructions

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