Remote Call Center Representative

We are seeking a dedicated Healthcare Customer Service Representative to join our team. This role involves assisting members with inquiries related to their insurance plans, eligibility, benefits, and claims. The ideal candidate will have a strong understanding of various insurance plan types and excellent communication skills.

We are a company committed to creating diverse and inclusive environments where people can bring their full, authentic selves to work every day. We are an equal opportunity/affirmative action employer that believes everyone matters. Qualified candidates will receive consideration for employment regardless of their race, color, ethnicity, religion, sex (including pregnancy), sexual orientation, gender identity and expression, marital status, national origin, ancestry, genetic factors, age, disability, protected veteran status, military or uniformed service member status, or any other status or characteristic protected by applicable laws, regulations, and ordinances. If you need assistance and/or a reasonable accommodation due to a disability during the application or recruiting process, please send a request to HR@insightglobal.com.

To learn more about how we collect, keep, and process your private information, please review Insight Global's Workforce Privacy Policy: https://insightglobal.com/workforce-privacy-policy/ .

Healthcare Basics

* Recognize and understand various insurance plan types, including Commercial, Individual Products, HIX, and Government Plans (Medicaid/Medicare).

* Familiarity with common insurance terminology and procedures.

Phone Skills

* Receive and respond to member inquiries via inbound calls using NICE inContact - Max Agent.

* Make outbound calls to members, vendors, and other departments.

* Follow established call flow processes for member interactions.

* Understand and apply protocols for using the language line for effective communication.

Eligibility and Enrollment

* Verify member status, including ID numbers and personal information, using Salesforce, CSC, and QNXT.

* Confirm member eligibility and plan effective dates.

* Manage member correspondence, including sending plan documents and updating demographics.

Provider Information

* Verify provider status (NPI, Tax ID) and understand provider types and specialties.

* Assess whether providers are Par or Non-Par and recognize specialty networks.

Website Assistance

* Educate members on using the Sentara/OHP website and assist in creating member accounts.

* Help members locate necessary forms and documents.

Benefits Administration

* Locate, interpret, and quote benefit information, including covered/excluded benefits and member out-of-pocket costs.

* Familiarity with various plan documents and protocols for coordination of benefits.

Authorizations

* Understand diagnosis codes (ICD 9-10) and procedure codes (CPT and HCPCS).

* Provide updates on authorization status and address member inquiries regarding pending or denied authorizations.

Claims Management

* Recognize and understand different claim types and statuses.

* Review claims details with members and assist with EOB inquiries.

Grievance and Appeals

* Initiate grievance and appeals requests over the phone and communicate with the G&A department as needed.

Collaboration

* Work closely with the Quality Team, L&D Team, and other departments to ensure high-quality service delivery.

Qualifications:

* High school diploma or equivalent; relevant experience in healthcare or customer service preferred.

* Strong communication and interpersonal skills.

* Proficiency in using CRM systems (Salesforce, QNXT) and call center software (NICE inContact).

* Ability to work in a fast-paced environment and handle multiple tasks efficiently.

Proposed Proficiency Timeframe:

* 90-day grace period for training and proficiency development.

Benefits:

* [Insert benefits information, e.g., health insurance, retirement plans, etc.]

Benefit packages for this role will start on the 31st day of employment and include medical, dental, and vision insurance, as well as HSA, FSA, and DCFSA account options, and 401k retirement account access with employer matching. Employees in this role are also entitled to paid sick leave and/or other paid time off as provided by applicable law.