CENTERLIGHT

Call Center Representative

• Manage a high volume of inbound and outbound calls professionally and efficiently
• Provide customer service to patients and families
• Schedule patient appointments using the electronic medical record (EMR) system
• Respond to inquiries about services, appointment availability, billing, and general information
• Assist with appointment rescheduling and cancellations
• Verify and update patient demographic and insurance information
• Educate patients about healthcare services, office policies, and available resources
• Document patient interactions and maintain accurate call records
• Document complaints and escalate complex issues to the appropriate department or supervisor
• Collaborate with clinical staff, administrative teams, and other departments
• Follow HIPAA regulations and maintain patient confidentiality and data security
• Achieve call quality, response time, and customer satisfaction goals
• Conduct outreach to callers regarding issue or request status and resolution
• Follow company, department, compliance, and Code of Conduct requirements

Call Center Specialist

Manager

• Lead daily operations of the appeals and grievances department, including intake, classification, assignment, investigation, resolution, documentation, and closure of participant and provider cases
• Supervise, coach, and evaluate A&G staff; establish performance expectations, provide feedback, support professional development, and address performance or workflow concerns
• Plan staffing and assign workloads based on volume, urgency, complexity, competency, and regulatory deadlines
• Maintain written processes for identifying, documenting, investigating, and resolving grievances and processing standard and expedited appeals
• Monitor pending cases, aging, due dates, extensions, expedited requests, adverse determinations, and closure documentation
• Review complex, high-risk, sensitive, or escalated cases and determine next steps using policy and regulatory guidance
• Coordinate fact-finding with clinical leaders, interdisciplinary teams, claims, provider relations, transportation, home care, compliance, legal counsel, delegated entities, and external providers
• Ensure appeals are reviewed by appropriately credentialed and impartial reviewers
• Review and approve acknowledgments, information requests, adverse determination notices, resolution letters, and other communications
• Ensure case records are complete, accurate, confidential, and maintained according to retention and audit requirements
• Develop and maintain A&G/SDR policies, procedures, workflows, templates, job aids, and training materials with the Call Center Director
• Conduct quality audits and inter-rater reliability reviews; develop corrective action plans and monitor improvement
• Analyze A&G/SDR data to identify trends, systemic issues, disparities, root causes, and process improvement opportunities
• Prepare and present weekly, monthly, quarterly, annual, and committee reports
• Integrate grievance and appeal findings into the organization’s QAPI program and monitor improvement actions
• Support audits, regulatory reviews, submissions, records requests, surveys, and corrective action responses
• Serve as the department escalation point and educate staff on recognizing, receiving, documenting, and routing grievances and appeals
• Promote participant rights, culturally and linguistically appropriate communication, confidentiality, non-retaliation, and participant-centered resolution
• Establish and monitor service levels, staff performance, and quality measures
• Adhere to organizational policies and perform other assigned duties

Call Center Specialist

Appeals and Grievances Manager