Provider Service Representative

About the role

The Provider Service Representative serves as the primary point of contact for providers and policyholders, handling inbound and outbound calls to resolve service needs, answer inquiries, and ensure compliance with health‑insurance regulations.

Key responsibilities

• Document, investigate, and resolve complex inquiries related to benefits, provider configurations, claim edits, eligibility, and Coordination of Benefits.
• Support a wide range of providers—including physicians, specialists, dentists, labs, and hospitals—both participating and non‑participating.
• Maintain HIPAA and data‑privacy compliance in all interactions and system usage.
• Educate providers on platform tools such as account creation, access recovery, and system functionalities.
• Provide feedback for continuous improvement, identifying service gaps and process inefficiencies.
• Handle inbound calls following protocols, aiming for first‑call resolution and accurate documentation.
• Meet KPIs for productivity, schedule adherence, call handling, quality, and documentation accuracy.

Required profile

• Bachelor’s degree, or at minimum 60 college credits/associate degree, or high school diploma with relevant experience.
• At least 6 months (or up to 2 years) of customer‑service experience in a health‑insurance call‑center environment.
• Intermediate proficiency in English and Spanish (reading, writing, speaking).
• Knowledge of medical billing preferred.
• Availability to work rotating shifts, including weekends and holidays.