Key Responsibilities and Required Skills for Licensed Healthcare Customer Service Representative

🎯 Role Definition

A Licensed Healthcare Customer Service Representative (Licensed CSR) serves as the primary point of contact for members, patients, providers, and internal stakeholders across telephonic and digital channels. This role requires a licensed or clinically credentialed professional who can accurately interpret benefits, verify eligibility, resolve claims and billing questions, and comply with regulatory requirements such as HIPAA and CMS guidance. The Licensed CSR combines strong customer-service skills with healthcare or insurance subject matter expertise to deliver timely, empathetic, and compliant resolutions while documenting interactions precisely in electronic systems.

This position is optimized for candidates with experience in healthcare call centers, payer/provider organizations, or clinical settings who hold the required state or professional license(s) and can translate complex clinical/insurance policies into clear guidance for members and providers.

📈 Career Progression

Typical Career Path

Entry Point From:

Healthcare Call Center Representative
Medical Receptionist or Front Desk Coordinator
Insurance Enrollment Specialist

Advancement To:

Senior Licensed Customer Service Representative / Subject Matter Expert
Team Lead / Supervisor, Member Services
Patient Advocate / Care Coordinator
Provider Relations Specialist
Claims Specialist or Appeals Coordinator

Lateral Moves:

Benefits & Eligibility Analyst
Enrollment & Outreach Specialist
Billing & Revenue Cycle Representative

Core Responsibilities

Primary Functions

Handle high-volume inbound and outbound calls, emails, and chat inquiries from members, patients, and providers, delivering clear, accurate, and empathetic answers about coverage, benefits, claims status, and provider networks while maintaining service-level targets.
Verify member identity and eligibility in accordance with company policies and HIPAA requirements, using multiple payer systems and state eligibility databases to confirm coverage details and plan effective next steps.
Interpret and explain complex health plan documents, benefit summaries, prior authorization requirements, deductibles, copays, coinsurance, and out-of-pocket maximums in plain language tailored to the caller’s level of health literacy.
Process enrollment, disenrollment, plan changes, and beneficiary updates in enrollment systems, ensuring all documentation is completed correctly and timelines for plan effective dates are met.
Review and adjudicate routine claims and payment inquiries or route complex claims to the appropriate claims team, providing members with clear next steps and expected timelines for resolution.
Support pre-authorization and referral workflows by collecting clinical and administrative documentation, submitting requests through the appropriate portals, and following up to communicate determinations and appeal rights.
Educate members about preventive care, wellness benefits, and network resources, including telemedicine options and behavioral health services, to improve engagement and care outcomes.
Document all member and provider interactions thoroughly in the CRM/EHR with accurate codes, notes, and disposition statuses to maintain audit-ready records and enable efficient follow-up.
Escalate urgent clinical or compliance-related issues to nursing staff, case managers, or supervisors in accordance with escalation protocols, ensuring timely response for members with acute needs.
Resolve billing and balance inquiries by researching claims, verifying contractual adjustments, determining patient responsibility, and coordinating payment arrangements or refunds as needed.
Coordinate with provider offices to confirm appointments, assist with referral authorizations, and help resolve scheduling conflicts or prior authorization delays that impact member access to care.
Respond to provider inquiries about credentialing, claim denials, and remittance advice, acting as a liaison between the provider and payer teams to facilitate timely resolution.
Maintain up-to-date knowledge of Medicare, Medicaid, commercial insurance policies, state regulations, and payer-specific plan benefits to ensure compliant and accurate guidance.
Perform structured outbound outreach campaigns for eligibility re-verification, care gap closures, and member retention efforts while accurately documenting contacts and outcomes.
Complete enrollment verification, formulary checks, and pharmacy benefit inquiries, collaborating with pharmacy teams and external PBMs to resolve medication access issues and prior authorization needs.
Support grievances and appeals intake by capturing all required information, explaining the appeals process, and preparing initial documentation for the clinical review team or appeals unit.
Use multi-line phone systems, CRM tools (e.g., Salesforce, Zendesk, or proprietary platforms), and EHR/EMR systems to manage workflows, update member records, and close tickets within established SLAs.
Monitor quality metrics and performance KPIs such as average handle time, first-call resolution, accuracy scores, and customer satisfaction, and implement coaching or process improvements to meet targets.
Follow all regulatory, privacy, and security policies (HIPAA, CMS, state DOH guidance), complete mandatory compliance and security training, and apply best practices when handling protected health information.
Support audit requests and internal quality reviews by preparing call recordings, documentation, and case files; respond to corrective action plans and implement process changes as directed.
Participate in continual learning and certification activities (including maintaining any required professional/insurance license) to ensure up-to-date knowledge of coverage rules, coding changes, and clinical guidelines.

Secondary Functions

Assist with development and maintenance of knowledge base articles, standard operating procedures (SOPs), and canned responses to improve accuracy and consistency across the team.
Provide training and mentoring to new hires and peer coaching to improve team performance and adherence to customer experience standards.
Participate in cross-functional projects to improve member onboarding, digital self-service adoption, and claim turnaround time reduction.
Support ad-hoc reporting requests by compiling member interaction trends, call drivers, and escalation patterns to inform quality improvement initiatives.
Contribute to the organization's patient experience and compliance strategy by identifying recurring issues and recommending policy or technology updates.
Collaborate with case management, utilization review, and clinical operations to translate member needs into coordinated care plans and engineering/IT requirements for system improvements.
Participate in sprint planning and agile ceremonies when supporting digital tool enhancements, knowledge base updates, or automation projects that impact customer service workflows.

Required Skills & Competencies

Hard Skills (Technical)

Active state license as required by the employer (e.g., health insurance producer license, life & health license) or applicable clinical license (LPN/LVN, RN) depending on role scope.
Deep working knowledge of health insurance products, Medicare Advantage, Medicare Part A/B/D, Medicaid, and commercial plan rules including eligibility, benefits, and billing.
Experience with CRM and case management platforms such as Salesforce, Zendesk, Avaya CMS, Genesys, or proprietary payer systems for ticketing and documentation.
Proficiency with EHR/EMR systems (e.g., Epic, Cerner) and pharmacy benefit management portals for status checks and prior authorization submissions.
Strong claims and reimbursement knowledge: claims adjudication processes, remittance advice interpretation, denial reasons, and appeals workflows.
Familiarity with HIPAA privacy, security standards, CMS regulations, and state-level healthcare compliance requirements.
Ability to use multi-line phone systems, call recording tools, and workforce management software to manage schedules and performance metrics.
Accurate and speedy data entry skills, including experience with eligibility verification tools and benefits research platforms.
Proficiency in Microsoft Office suite (Excel for reporting, Outlook for communication) and ability to generate basic reports and analyze call metrics.
Bilingual proficiency (e.g., Spanish/English) preferred or required depending on population served; medical translation experience is a plus.

Soft Skills

Exceptional verbal and written communication with the ability to simplify complex clinical and insurance information for diverse audiences.
Active listening and empathy, especially when handling members experiencing stress, confusion, or urgent medical concerns.
Strong problem-solving and critical thinking to triage inquiries, determine root causes, and identify appropriate next steps or escalations.
De-escalation and conflict-resolution skills to manage upset or frustrated callers while preserving a positive member experience.
High attention to detail and accuracy when documenting sensitive health information and following regulatory procedures.
Time management and prioritization to juggle multiple tasks while meeting service level agreements and quality standards.
Team collaboration and flexibility to work across clinical, operational, and technical teams to resolve complex member issues.
Continuous learning mindset and adaptability to changing regulations, benefits, and platform updates.
Professionalism and ethical judgment when exercising discretion with protected health information and member-sensitive situations.
Customer-focused orientation with a drive to improve satisfaction, retention, and overall patient outcomes.

Education & Experience

Educational Background

Minimum Education:

High school diploma or GED required.

Preferred Education:

Associate's degree or Bachelor's degree in Nursing, Health Administration, Business, Public Health, or a related field preferred.
Continuing education or certifications in healthcare administration, case management, or customer service are a plus.

Relevant Fields of Study:

Nursing (RN, LPN/LVN)
Health Administration or Health Services Management
Public Health
Social Work
Insurance/Finance

Experience Requirements

Typical Experience Range:

1–5 years of experience in healthcare customer service, payer/provider contact center, medical office coordination, or insurance support roles.

Preferred:

2+ years in a licensed healthcare customer support role or clinical contact center, with demonstrated experience handling Medicare/Medicaid inquiries, claims resolution, or prior authorization workflows.
Prior experience maintaining required state insurance licenses or clinical credentials, and working knowledge of HIPAA and CMS guidelines.