Customer Service Specialist

TakeCare Insurance Company, Inc.; Tamuning (GU); On-site; USD 36,000 - 56,000; Full time

Job summary

TakeCare Insurance Company, Inc. is seeking a Customer Service Specialist to enhance member satisfaction and productivity.

You will receive, document, and resolve escalated inquiries, complaints, appeals, and grievances, gathering data for medical reviews and coordinating resolution across internal teams and external contacts. You will serve as a liaison among members, providers, and employer groups, educating on benefits and claims status while maintaining high professionalism and integrity.

Qualifications

• High school diploma or equivalent.
• 1 year experience in Customer Support.
• Healthcare experience and/or clinic administration preferred but not required.
• Must have the behavioral sensitivity, maturity, diplomacy and tact in addressing complex situations and handling irate customers.
• Exceptional customer service skills including effective and efficient problem solving and analyzing skills.
• Ability to perform essential job functions with high degree of independence, flexibility, and creative problem solving techniques.
• Ability to effectively handle and prioritize multiple tasks, frequent interruptions and details with accuracy.
• Strong organizational skills.
• Outstanding oral and written communication skills.
• Skill with interpersonal relationships and ability to effectively interact with all levels of staff and outside contacts.
• Strong ethics and a high level of personal and professional integrity.
• Must have basic familiarity on federal and state laws and requirements relating to healthcare management.
• Computer-literate and very highly proficient in using MS office programs.

Responsibilities

• Serve as liaison between customer service team, management and customer to improve service and productivity.
• Analyze customer complaints and provide corrective actions.
• Assist in training peers on improving customer service.
• Receive, document, research and respond to member inquiries, complaints, appeals, and grievances.
• Prepare and/or initiate correspondence/documents responding to inquiries, complaints, appeals and grievances.
• Gather and present data of cases for medical review and make recommendations for resolution or next steps.
• Coordinate problem resolution for members, providers, and employer groups across departments and external contacts.
• Educate members on benefits, plan use, premiums and status of claims, appeals, grievances.
• Act as department resource with knowledge of simple matters and guide staff.
• Collect updated member demographics.
• Handle special projects like Grievance/Appeal Coordinator roles and ensure timely reviews.
• Perform other duties as assigned.

Skills

Customer service

Problem solving

Communication

Interpersonal skills

Organizational skills

Education

High school diploma or equivalent

Tools

MS Office

Job description

Job Summary:

As a Customer Service Specialist, you will play a pivotal role in enhancing customer satisfactionand business productivity. Reporting directly to the Customer Service Supervisor, you will beresponsible for receiving, documenting, and resolving escalated member inquiries, complaints,appeals, and grievances. You will gather and present all relevant data of case for medical reviewand will make recommendations for resolution and/or determination of next step. Alsoresponsible for coordinating problem resolution for members, providers, and employer groups amongst various internal departments and external resources/contacts.

Essential Duties and Responsibilities:

• Serve as liaison between customer service team, management and customer to improvecustomer service and business productivity.
• Analyze customer complaints and provide appropriate corrective actions.
• Assist in training peers on improving customer service.
• Receives, documents, researches and responds to member inquiries, complaints, appeals, andgrievances from callers and visitors.
• Prepares and/or initiates a variety of correspondence/documents in response to inquiries,complaints, appeals and grievances.
• Gathers and presents all relevant data of case for medical review and makes recommendations for resolution and/or determination of next step.
• Coordinates problem resolution for members, providers, and employer groups amongstvarious internal departments and external resources/contacts.
• Educates members on benefits, use of plan, premiums and status of claims, appeals, andgrievances.
• Acts as designated department resource with extensive knowledge of simple matters andprovides guidance to other staff members.
• Accumulates and collects updated member demographics.
• May be assigned special project, such as Grievance Coordinator/Appeal Coordinator.Responsible for receiving and documenting all written grievances/appeals and for facilitating timely review and responses from respective parties.
• Performs other duties that may be assigned from time to time.

Education & Experience:

1. High school diploma or equivalent.
2. 1 year experience in Customer Support.
3. Healthcare experience and/or clinic administration preferred but not required.
4. Must have the behavioral sensitivity, maturity, diplomacy and tact in addressing complex situations and handling irate customers.
5. Exceptional customer service skills including effective and efficient problem solving and analyzing skills.
6. Ability to perform essential job functions with high degree of independence, flexibility, and creative problem solving techniques.
7. Ability to effectively handle and prioritize multiple tasks, frequent interruptions and details with accuracy.
8. Must have strong organizational skills.
9. Outstanding oral and written communication skills.
10. Skill with interpersonal relationships and ability to effectively interact with all levels of staffand outside contacts.
11. Strong ethics and a high level of personal and professional integrity.
12. Must have basic familiarity on federal and state laws and requirements relating to healthcaremanagement.
13. Computer-literate and very highly proficient in using MS office programs.