DE/Customer Service Representative

firstsourc•Remo, VA

About The Position

This is a full-time, non-exempt/hourly position in the Health Plan and Healthcare Services department, reporting to a Team Lead/Supervisor - Operations. The role involves reviewing incoming Grievance and Appeals documents, identifying and assigning the correct Line of Business (LOB), and classifying dispute types according to client-specific guidelines. The CSR/Data Entry will access multiple client systems to retrieve and validate member information, index documents by entering data into internal systems or client platforms, and normalize documents as needed. Adherence to HIPAA, data privacy, and security requirements is crucial. The position requires meeting productivity, accuracy, and quality standards, following client-specific workflows, and identifying/escalating discrepancies. Participation in quality audits, training, and process improvement initiatives is also expected.

Requirements

Proficiency in reviewing documents for completeness, legibility, and relevance.
Ability to accurately identify and assign Lines of Business (LOB).
Skill in classifying dispute types according to guidelines.
Experience accessing and navigating multiple client systems and portals.
Proficiency in retrieving, verifying, and validating member information.
Accuracy in indexing documents and entering data into internal systems or client platforms.
Ability to normalize and prepare documents.
Strict adherence to HIPAA, data privacy, and security requirements.
Ability to meet productivity, accuracy, and quality standards.
Familiarity with client-specific workflows, job aids, and standard operating procedures.
Skill in identifying and escalating discrepancies, missing information, or indexing issues.

Nice To Haves

Experience with Grievance and Appeals processes.
Familiarity with health plan and healthcare services operations.
Experience with quality audits, training updates, and process improvement initiatives.

Responsibilities

Review incoming Grievance and Appeals documents for completeness, legibility, and relevance.
Accurately identify and assign the correct Line of Business (LOB) based on client and regulatory definitions.
Determine and classify the dispute type (e.g., grievance, appeal, expedited appeal, standard appeal) in accordance with client-specific guidelines.
Access multiple client systems and portals to retrieve, verify, and validate member information, including but not limited to: Member demographics, Member ID numbers, Plan and eligibility details.
Index documents by entering required data fields accurately into internal systems or client platforms.
Normalize and prepare documents when required to ensure all necessary information is available for downstream processing.
Adhere to all HIPAA, data privacy, and security requirements when handling protected health information (PHI).
Meet established productivity, accuracy, and quality standards.
Follow client-specific workflows, job aids, and standard operating procedures.
Identify discrepancies, missing information, or indexing issues and escalate according to established procedures.
Participate in quality audits, training updates, and process improvement initiatives as required.