Customer Service Representative

Manage, coordinate, and resolve member and provider complaints, grievances, and appeals, ensuring compliance with state and federal regulatory requirements. Act as primary investigator and contact for members/providers, perform research, resolution, and response to complaints. Responsibilities include acknowledging grievances/appeals, educating members/providers about the process, gathering relevant information, determining appropriate resolution per policies, notifying parties of resolutions, conducting non-biased investigations, and thoroughly documenting actions.