CUSTOMER SERVICE AGENT

Essential Functions

• Processes a high volume of service authorization requests received via fax, phone, and online portals.
• Verifies member eligibility and benefits, documents relevant clinical and administrative information 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.

Requirements

• 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.
• Working knowledge of HIPAA regulations is beneficial.
• Previous customer service experience within the healthcare or health insurance industry is preferred.