Call Center Representative – Healthcare

September 9, 2021
San Jose, CA
Job Type



Our growing health management organization is seeking an enthusiastic Provider Relations Call Center Representative to support our Member and Provider Services team as we scale the business. Working closely with fellow team members, this position answers member and provider inquiries in an efficient and comprehensive manner. Main responsibilities include answering and assisting callers, accurately logging call details, and working on special projects, as assigned. The successful candidate has experience in a call-center setting, demonstrates unprecedented customer service skills, has at least one year of healthcare billing experience in an office setting, and is self-motivated and a quick learner, and is able to work efficiently while maintaining organizational policies and procedures required for compliance.


1. Answer and manage large amounts of incoming member and provider calls and voicemails regarding claims, authorizations, benefits, etc. in a timely manner in accordance with departmental performance targets.

2. Maintain productive and positive communication with business divisions such as Health Services, Claims, Credentialing, and Contracting in order to provide the most up-to-date and accurate information.

3. Document call details clearly and concisely to align with department standards.

4. Use critical thinking to solve problems rapidly, independently, and creatively; Drive resolution of member and provider inquiries in real-time or through timely follow-up with outbound calls.

5. Continually maintain learning and understanding of claims and authorization compliance regulations through company trainings and independent research.

6. Assist in developing departmental KPIs and targets to promote the continuous improvement of provider and member relations effectiveness.

7. Uphold and maintain confidentiality and compliance requirements as defined by organizational policies and procedures; Be able to discuss sensitive information respectfully.

8. Perform other duties and special projects, as assigned.


• High school diploma (or equivalent) required. AA, BA, or BS preferred.

• Strong customer service background (1-2 years) required.

• Healthcare industry experience strongly preferred. Managed care experience in areas of customer service, billing, claims payment, claims resolution, and/or provider services, a plus.

• Excellent critical thinking and problem-solving skills.

• Experience in basic computer applications such as Microsoft Outlook, Word, and Excel.

• Ability to comprehend detailed information and communicate comprehensibly; determine immediate requests and identify and address current and future needs of the caller.

• Ability to retain information and work with minimal supervision, after training.

• Must be team-oriented and focused on achieving organizational goals; must demonstrate accountability.

• Be able to build rapport with members and providers in a professional manner by providing respectful and timely responses.

• Must be comfortable interacting with external and internal customers and diffusing potentially tense situations.

• Knowledge of CMS 1500 and UB 92 claims forms.

• Familiarity with medical terminology and basic CPT codes.

• Ability to work regularly scheduled shifts within business hours of operation with scheduled lunches/breaks and the flexibility to work overtime/weekends, if needed.


• The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

• While performing the duties of this position, the employee is regularly required to sit and use hands to finger, handle, or feel objects, tools or controls. The employee is frequently required to reach with hands and arms and talk or hear. The employee is occasionally required to walk.

• The employee must be able to lift and move up to 25 pounds. Specific vision abilities required by this position include close vision, color vision and the ability to adjust focus.

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