Assesses and research customer service needs, determines causes, and initiates corrective actions to other service or technical departments for follow up as needed.Provides guidance on various complex member or provider issues to resolve customer’s inquiries or requests.Provides member or providers with information and resources to further educate relevancy to the complex inquiry or concern.Provides customer service in a high pace contact center environment over the phone, via live chats and emails.Continues to develop in-depth knowledge and deep expertise in multiple additional markets and/or plans in multiple subject areas and responds to complex or escalated questions.May lead the team in member or provider request resolution and collaborates inter- departmentally to resolve inquiries or concerns.Identifies, documents, and resolves all customer information and communications and updates leadership on customer needs thru root cause analysis, recommendation and resolution.Collaborates with training teams to develop training materials and/or programs to ensure quality and adherences to policies and procedures.Records all activities for quality and metrics reporting through the Customer Relationship Management (CRM) application, including customer interactions, details of inquiries, complaints, comments, and final resolution.Adheres to quality standards, regulations, and confidentiality through the various communication channels.Participates in special projects as needed also performs other duties as assigned.

Serve as a liaison between Customer Service Representatives CSRs), management and other various departments. Resolve customer inquiries via telephone and written correspondence in a timely and appropriate manner.Investigate and resolve complex claims matters in coordination with health plan and/or corporate departmentsCoordinate the day-to-day work functions, acting as a “go to” person and investigating and resolving complex issuesInitiate change requests to resolve system configuration questions impacting claims processing; review and test resultsConduct appropriate auditing processesReference current materials to answer escalated and complex inquiries from members and providers regarding claims, eligibility, covered benefits and authorization status mattersEducate members and/or providers on health plan initiatives; train and assist providers regarding proper claims billing proceduresProvide first call resolution and “own the process” by working with appropriate internal/external resources and ensure the closure of all inquiriesDocument all activities for quality and metrics reporting through the Customer Relationship Management (CRM) applicationIdentify trends related to member and/or provider inquiries to respond proactively and provide feedback to managementCollaborate with other departments on cross functional tasks and projects Maintain performance and quality standards based on established call center metrics including turn-around times