Customer Service Representative II

Department:
Ops - Member Services

Location:
9700 Flair Drive, El Monte, CA 91731

Compensation:
$20.00 / hour

Description
Job Title: Customer Service Level II

Department: Customer Service Department

About the Role:
Astrana Health is looking for a Customer Service Level II - Problem Solver to join our fast and growing Dynamic team.
Must be fluent in speaking Spanish
.

You are:

• Comfortable with ambiguity and biased towards action
• Relentlessly resourceful
• Growth-oriented
• Mission-driven

What You'll Do

• Monitor and manage a high volume of cases daily, including calls, chats, SMS, and emails
• Accurately log all interactions in the system
• Collaborate with departments such as UM, Eligibility, and Claim to resolve issues
• Adhere to internal policies for documentation, escalation, and communication standards
• Follow up with members/providers to prevent repeat inquiries and ensure closure
• Use appropriate applications, approved scripts, and response time guidelines for all chat/SMS inquiries
• Keep all stakeholders informed through proper documentation and communication channels
• Assist with Member Outreach Projects such as Return Mail, Quality Care Measures, Annual Wellness Visit, Member Retention, etc
• The Problem Solver may take on other tasks as required to support team or organizational needs
• All other duties as assigned

Claims Resolution:

• Handle incoming member calls related to claims and ensure all necessary claim details are captured
• Verify member eligibility for the date of service (DOS)
• Requesting supporting documents or detailed claims data if a statement is not available
• If no prior ticket exists, create a new ticket; otherwise, update the original ticket with new information
• Contact internal stakeholders (Eligibility Team or designated contact) to confirm eligibility or Other Health Coverage (OHC) as needed
• Log and track all member billing cases in the Member Bill Log and update ticket statuses weekly
• Provide fax, mail, and email options to members who cannot immediately supply the required information
• Maintain compliance with documentation and communication standards

Eligibility:

• Complete assigned eligibility related requests, including tickets, SMS chats, website chats, and eligibility emails
• Provide support to teammates through Teams Chat for urgent eligibility checks
• Communicate effectively with the internal Eligibility Department
• Verify and cross reference member eligibility using Astrana applications and Health Plan websites
• Submit updates and ensure all proper documentation is included with eligibility update requests
• Support inbound calls during periods of high call volume

Utilization Management (UM):

• Review incoming tickets for cases requiring authorization or referral status follow up
• Investigate UM related issues such as status of pending authorizations, or incorrect denials
• Understand and apply UM guidelines for referral duration, exceptions, and proper department routing
• Contact UM coordinator directly for urgent cases and escalate unresolved issues by protocol
• Document all outreach attempts (3-contact rule) and ensure complete follow-through or escalation to the UMCS Supervisor if necessary
• Ensure the provider/member is informed once a case is resolved or if significant delays occur

Qualifications

• High School Diploma or GED
• Experience using Microsoft applications such as Word, Excel and Outlook
• Minimum 1-2 years of healthcare customer service experience
• Strong knowledge of eligibility verification, claims, billing, and UM workflows
• Exceptional communication and problem-solving skills
• Ability to multitask in a high volume, fast paced environment
• Strong attention to detail and organizational skills
• Team oriented with the ability to work independently with minimal supervision
• You are fluent in speaking Spanish

You're a great for this role if:

• You have previous work experience working in a healthcare setting

Environmental Job Requirements and Working Conditions

• The national target pay range for this role is $20.00 per hour. Actual compensation will be determined based on geographic location (current or future), experience, and other job-related factors.
• This position will typically work Monday - Friday from 8:30am to 5:00pm Pacific Time.
• This is a remote role. The home office is aligned with your department at 9700 Flair Drive, El Monte, CA 91731.

Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based on race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided based on qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at

to request an accommodation.

Additional Information:
The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.

Salary : $20