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  • Anaheim, CA

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Customer Service Representative

The Judge Group • Anaheim, CA

Posted 26 days ago

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Customer Service

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Job Description

The Judge Group is looking for a Customer Service Rep in Anaheim, CA 

Position Summary:
  • The Customer Service Representative communicates with a diverse constituency of internal and external customers and responds to individual questions and concerns specific to organizational determinations, claims, plan benefits, coverage determinations, disputes, and questions or issues related to payment methodology. Receives and responds to calls from providers and members. Transfers calls as necessary to applicable department, such as, but not limited to, utilization management, or to applicable Health Plan as appropriate. Conducts inquiries and research related to provider and member questions and concerns, including claims and authorization status and related information, and documents all calls and responses. Relays plan contact information to providers and members as applicable and appropriate.
Essential Job Functions:
  • Receives inbound calls and responds appropriately to provider, or member, questions and/or concerns.
  • Answers calls timely and in accordance with the performance standards established within the customer service department.
  • Provides information as requested related to coverage determinations and appeals processes.
  • Provides information as requested by caller related to claims and authorizations.
  • Facilitates provider and member communications related to network providers.
  • Responds to provider dispute queries.
  • Provides plan contact information as applicable to members and providers.
  • Facilitates communication through the Language Assistance Program (for members who are not English proficient) of the various plans, and/or arranges for interpreter, including interpretive services for the hearing impaired.
  • Maintains applicable and timely records and files regarding member and provider communications and service coordination.
  • Reviews all documents received for completeness, verifies eligibility member
  • Verifies claims status and coordinates information, as applicable, with provider and claims staff.
  • Forwards calls as appropriate to supervisor or other staff for further response or follow up.
  • Ensures confidentiality of all hard copy, electronic, and verbal communication, and adheres to organization’s policies related to privacy and disclosure.
  • Promotes a positive image of the organization and the department in all aspects of communication and contact.
  • Performs other duties as assigned.
Other Job Functions:
  • Understand, adhere to, and implement the Company’s policies and procedures.
  • Provide excellent customer services skills, including consistently displaying awareness and sensitivity to the needs of internal and/or external clients. Proactively ensuring that these needs are met or exceeded.
  • Take personal responsibility for personal growth including acquiring new skills, knowledge, and information.
  • Engage in excellent communication which includes listening attentively and speaking professionally.
  • Set and complete challenging goals.
  • Demonstrate attention to detail and accuracy in work product.

Required Qualifications:
  • Previous experience in Customer/Member services or related function within a CALL CENTER in health care organization preferred.
  • Experience in a managed care environment preferred.
  • Demonstrated experience and expertise in customer service skills: excellent verbal and written communication skills, handling difficult communications with skill to achieve positive outcome, clear and concise targeted communications focused on the customer (verbiage, language, style, etc. all may vary depending on the customer/audience).
  • Bilingual (English/Spanish) preferred
Please send your most up to date resume to Jaclyn at
Job ID: 601416
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