Customer Service Representative - I - SC -Fajardo

MCS Healthcare Holdings, LLC (MCS)•Fajardo, PR

About The Position

The Customer Service Representative I – SC assists customers and prospects by providing information about the company’s products and services, clarifying beneficiaries’ questions and concerns, and resolving service needs in accordance with established operational processes and service guidelines. The representative documents services and actions taken to support continuity of service at the Service Center. The role handles customer inquiries and requests involving policyholder and dependent eligibility, cancellations, provider changes, duplicate cards, coverage certifications, beneficiary value programs, collections, and reimbursement requests. It also maintains policyholder demographic information, registers visitors, evaluates service situations, logs and follows up on cases, handles escalated or complex calls, refers complaints to the appropriate unit, and supports other departments with service requests and Health Risk Assessment calls.

Requirements

One of the following education and experience combinations: bachelor’s degree from an accredited institution and at least six months of experience in a similar Customer Service role; 60–64 college credits, equivalent to two years of study, or an associate’s degree and at least one year of Customer Service experience; or a high school diploma and at least two years of Customer Service experience.
Customer Service experience preferably in a Call Center in the Health Insurance Industry.
Customer-service orientation.
Knowledge of keyboard and telephone etiquette.
Intermediate Spanish comprehension, writing, and verbal skills.
Intermediate English comprehension, writing, and verbal skills.

Nice To Haves

Experience in a Call Center in the Health Insurance Industry.

Responsibilities

Handle and resolve service requests from customers and prospects, including inquiries about eligibility, cancellation letters, IPA and PCP changes, duplicate cards, coverage certifications, beneficiary value programs, utility and premium collections, and reimbursement requests.
Prepare coverage certifications and letters of non-covered services according to policyholder requests.
Maintain current policyholder demographic information in company systems.
Register visitors and assess each member’s service situation to identify improvement areas and determine an appropriate course of action.
Meet established service standards, including wait times, service quality, transaction accuracy, and error rates.
Log cases in systems or applications and work cases received through the CRM case referral tool.
Keep customers informed about request status and outcomes.
Document steps taken to complete service cycles, follow documentation parameters, and prepare transaction reports.
Handle calls referred from the company’s Call Center concerning complex questions or concerns about benefits, processes, and coverage.
Complete follow-up service cycles for calls not resolved on first contact or when follow-up has been promised.
Refer policyholder complaints to the appropriate unit according to established protocol.
Receive, document, resolve, or route service requests from other departments to support customer retention and ensure a response is received.
Support other departments by completing Health Risk Assessment calls.
Comply with company policies and procedures, applicable local and federal laws, and industry regulations.
Carry out other duties and responsibilities as assigned, consistent with the education and experience requirements.