Customer Service Specialist 1 | Calamba Office

JOB PURPOSE

The Customer Service Specialist 1 reviews and approves members' requests for consultations and procedures based on their healthcare benefits, particularly for Outpatient and Dental services. The role provides member support, answers inquiries, and ensures requests are processed accurately in accordance with benefit plan coverage, contributing to customer satisfaction and client retention.DUTIES & RESPONSIBILITIES

Answer inquiries from members, healthcare providers, and accredited medical facilities regarding healthcare benefits, coverage, and availment procedures. Receive, review, and process requests for consultations, procedures, and other healthcare services based on members' benefit plans. Verify member information, eligibility, benefit coverage, accredited doctors and facilities, and applicable limits before issuing approvals. Ensure that all approvals are processed in accordance with company policies, benefit guidelines, and established levels of authority. Maintain accurate and complete records of transactions, approvals, inquiries, and related activities. Identify potential abuse, misuse, or fraudulent claims and immediately escalate and report such cases to the appropriate department heads for investigation. Deliver excellent customer service to promote member satisfaction and contribute to client retention.JOB QUALIFICATIONS

Educational Requirement- Graduate or undergraduate of any Allied Medical Course; or Graduate or undergraduate of any Bachelor's Degree with at least six (6) months of experience in the HMO industry. Relevant Work Experience- Experience in an HMO setting, healthcare industry, or medical facility is an advantage. Personal Characteristics and Behaviors- Effective communication skills in both oral and written formats.- Patient and empathetic in dealing with members, providers, and colleagues.- Ability to multitask and work efficiently under pressure.- Willingness to learn and adapt to changes in processes and procedures.- Willing to work on shifting

schedule

s (morning, mid, and night shifts). Required Competencies- Strong critical thinking and problem-solving skills to analyze and resolve customer service concerns while exercising sound judgment and initiative.- Good communication and active listening skills.- Computer literate and proficient in basic office applications.- Typing speed of at least 45 words per minute (WPM).- Strong attention to detail and accuracy.- Ability to review and process healthcare requests in accordance with benefit plan provisions, company guidelines, and service standards.