Customer Care Representative - Customer Service

Position Overview

TheCustomer Care Representativeapplies knowledge and sound communication skills to investigate and independently resolve telephone and in-person inquiries from customers and providers regarding health benefits, claims, authorizations, prescriptions, providers, eligibility, enrollment, and any other plan-related questions. They will make each interaction effortless by creating forward-moving, solution-oriented conversations and providing complete and accurate solutions for an easy, enjoyable, and seamless customer experience.

Key Responsibilities

• Builds customer loyalty and trust by being a solution-minded advocate who educates, empowers, and supports our customers throughout their Health First wellness journey.
• Guides customers through their inquiries to successful resolution by actively listening, creating two‑way conversations, and utilizing critical thinking.
• Recognizes the customer’s initial inquiry and proactively identifies any underlying or unspoken needs by asking probing questions to guide the customer through complex issues.
• Offers each customer a personalized solution and time frame to meet their needs, and provides alternative options in adherence to applicable department policies when a customer’s preferred resolution is not available.
• Supports fellow associates and models excellence in service behavior for customer inquiries.
• Assists with customer requests for benefit, reimbursement, or plan documents to be sent via mail, fax, and email while exercising advanced knowledge ofHIPAA guidelines.
• Assists with customer service walk‑in members in a timely and efficient manner.

Required Qualifications

• Education: High School/GED
• Licensure: None
• Certification: None
• Work Experience: One (1) plus years of experience as a HFHP Customer Care Associate
• Knowledge/Skills/Abilities:
• Demonstrated understanding of prescription drug coverage concepts, eligibility, coverage, claims, and payment provisions.
• Familiarity with processes and procedures for member appeal and grievance rights including coverage and organization determinations.
• Proficiency with core applications including administrative, pharmacy, utilization management, claims, enrollment, and payment systems, Microsoft applications, and member, broker, and provider portals.
• Knowledge of Health First Health Plans’ call center and administrative operations.
• Excellent verbal, written, and interpersonal communication skills that model I‑CARE values and provide a seamless and delightful customer experience.
• Consistent achievement of productivity and quality metrics.

Preferred Qualifications

• Education: Bachelor’s degree in Business, Health Care Administration, or related field from an accredited college or university
• Work Experience: Coaching experience in a customer service environment

Physical Requirements

• Majority of time involves sitting or standing; occasional walking, bending, stooping.
• Prolonged periods of computer use or workstation time.
• Light work that may include lifting or moving objects up to 20 pounds with or without assistance.
• May be exposed to varied temperatures, air quality, lighting and/or low to moderate noise levels.
• Involves communicating with others to exchange information.
• Requires visual acuity and hand-eye coordination to perform tasks.
• Workspace may vary from open to confined; on site or remote.
• May require travel to various facilities within and beyond the county perimeter; may require use of personal vehicle.