Commercial Health Customer Service Representative- Remote

Evry Health provides technology-enabled commercial health insurance focused on accessible, transparent, and personalized member support. The Customer Service Representative serves as the primary contact for members and providers, handling inquiries and explaining benefits, eligibility, claims, and billing while resolving issues and documenting interactions.

Responsibilities:

• Member & Provider Inquiry Resolution: Researches, reviews, and responds to inbound and outbound member and provider inquiries, using knowledge of benefits, eligibility, claims, and billing to resolve issues at first contact when possible. Meets all turnaround times and department metrics, including quality, AHT, ASA, schedule adherence, etc
• Benefits, Eligibility & Claims Explanation: Accurately interprets and explains plan benefits, eligibility, cost-sharing, and claims payment decisions, applying working knowledge of CPT, ICD-10, HCPCS, and Revenue Codes.  Provides support to providers which includes claim status, prior authorization requirements, payment details. Supports pharmacy and wellness vendor inquiries
• Escalation: Owns initial intake and documentation of escalated member and provider situations
• Cross-Functional Collaboration & Documentation: Collaborates with Claims, Medical Management, and other internal teams to resolve complex issues, and accurately documents every interaction in the designated CRM system
• Trend Recognition & Member Portal Support: Monitors personal call/inquiry patterns to surface trends to leadership and assists members with portal navigation while promoting long-term digital self-sufficiency

Requirements:

• At least two years of experience in customer service supporting a commercial health plan (not just Medicare, Medicaid, or Pharmacy) is required
• Eligible candidates also must live in/work from the United States in either the CST or EST time zone
• High school diploma or equivalent required
• 2+ years of customer service experience supporting commercial fully insured health plan business
• Working knowledge of commercial health plan benefits, eligibility & claims processes
• Demonstrated knowledge of CPT, ICD-10, HCPCS & Revenue Codes
• Microsoft 365 proficiency required
• Associate's or Bachelor's degree in business, healthcare, or related field
• Experience supporting Claims, Medical Management, and/or Appeals and Grievance functions
• Proficiency with Salesforce or a comparable CRM system
• Experience identifying/reporting call trends or serving in an informal team lead/quality capacity