Customer Service Representative , Health Plan; Pennsylvania resident

Overview

Assists in resolving customer concerns, providing appropriate education and instruction, and maintaining customer satisfaction by delivering the highest level of customer service in one of the primary functions: enrollment, claims, or phone support. Actively participates in cross‑training and process improvement within the Customer Service team.

• Resolves and reconciles enrollment reports and all related eligibility issues by following policy and procedures, state legislated coverage and eligibility guidelines.
• Initiates communication and literature to newly enrolled Health Plan members, dependents, and employer groups.
• Interprets and appropriately applies rules and regulations in contractual agreements with employer groups and vendors.
• Performs membership data extract reports and supplies them to employer groups as an audit tool for accuracy and compliance with performance‑risk guarantee commitments.
• Updates, approves, and interprets membership data and workflow produced by online software capabilities in employer group modules.
• Determines eligibility of most members, processes terminations and disenrollments.
• Prepares, generates, and disseminates letter communications to subscribers and members regarding enrollment activity.
• Determines if services received are covered benefits as applicable by line of business and product design.
• Reviews suspended claims for resolution by applying current policies, procedures, and benefits applicable to specific products.
• Provides team‑building resources to assist peers in proper claims resolution policies and procedures to assist members and providers.
• Provides daily support and advice to member and provider services staff regarding claims issues.
• Researches claim issues from participating providers and identifies specific criteria for reconsideration for payment.

Work is typically performed in an office environment. The employee is accountable for satisfying all job‑specific obligations and complying with all organization policies and procedures.

High School Diploma or Equivalent (GED) – Required

Minimum of 1 year Customer Service – Required

None required.

Everything we do is about caring for our patients, members, students, and communities. Our core values are Kindness, Excellence, Learning, Innovation, and Safety. We offer comprehensive healthcare benefits to full‑time and part‑time positions from day one, including vision, dental, and domestic partners, and we commit to fostering an inclusive and collaborative work environment.

We are an affirmative action, equal opportunity employer. All qualified applicants will receive consideration for employment regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or veteran status.