The posting
Healthcare Customer Service Representative – Patient Access / Prior Authorization
Position Overview
The Healthcare Customer Service Representative (CSR) provides support to patients, healthcare providers, and insurance members by assisting with insurance eligibility and benefits verification, prior authorization requirements, and pre-service estimates. The role ensures accurate and timely handling of patient inquiries while helping patients understand their insurance coverage, financial responsibilities, and requirements for receiving healthcare services.
The ideal candidate has strong communication and customer service skills, attention to detail, and preferably experience in U.S. healthcare, insurance, patient access, revenue cycle management, or medical billing.
Key Responsibilities
Insurance Eligibility & Benefits
- Verify patient insurance eligibility and coverage using payer websites, portals, and internal systems.
- Review insurance benefits, coverage limitations, deductibles, copayments, coinsurance, and out-of-pocket responsibilities.
- Identify and communicate authorization, referral, or coverage requirements.
- Update and maintain accurate patient insurance and demographic information.
- Coordinate with insurance carriers and healthcare providers to resolve eligibility and coverage issues.
Prior Authorization
- Review services and determine whether prior authorization is required based on insurance guidelines.
- Initiate and submit prior authorization requests to insurance payers.
- Gather required clinical, patient, and service information from appropriate sources.
- Monitor authorization requests and follow up with payers regarding pending or outstanding requests.
- Document authorization status, reference numbers, and payer communications accurately.
- Escalate denied, delayed, or complex authorization cases to the appropriate team.
Pre-Service Estimates / Financial Clearance
- Review scheduled services and insurance benefits to assist in determining estimated patient financial responsibility.
- Calculate or communicate estimated copayments, deductibles, coinsurance, and other applicable patient costs based on available information.
- Explain estimates and insurance-related financial information clearly and professionally to patients.
- Identify discrepancies or missing information that may affect the accuracy of an estimate.
- Coordinate with insurance verification, authorization, billing, and patient access teams to resolve issues before the scheduled service.
- Maintain accurate documentation of estimates, patient communications, and financial clearance activities.
Customer Service & Patient Support
- Handle inbound and/or outbound calls from patients, providers, and insurance companies.
- Provide clear and empathetic assistance while maintaining patient privacy and confidentiality.
- Educate patients regarding insurance coverage, authorization requirements, and estimated financial responsibility.
- Resolve inquiries and concerns within established service-level and quality standards.
- Demonstrate professionalism when handling sensitive financial and healthcare-related information.
- Escalate complex issues appropriately while maintaining ownership of the customer experience.
Documentation & Compliance
- Accurately document all interactions, verification results, authorization activities, and patient communications in the appropriate systems.
- Follow HIPAA, payer requirements, client policies, and established healthcare processes.
- Maintain confidentiality and security of protected health information (PHI).
- Meet established productivity, quality, accuracy, attendance, and customer service metrics.
- Perform other healthcare customer service or patient access-related duties as assigned.
Qualifications
- At least 1–2 years of experience in a healthcare BPO, medical billing, insurance, patient access, or related healthcare environment preferred.
- Experience in one or more of the following is highly preferred: Prior Authorization Insurance Eligibility & Benefits Verification Pre-Service Estimates Financial Clearance Patient Access Medical Billing / Revenue Cycle Management
- Strong verbal and written English communication skills.
- Excellent customer service and interpersonal skills.
- Strong attention to detail and ability to handle sensitive information accurately.
- Ability to navigate multiple systems, payer portals, and healthcare applications.
- Comfortable handling high-volume calls and working in a fast-paced healthcare environment.
- Willingness to work on a shifting schedule, including night shifts, weekends, or holidays, as required by the business.
Preferred Skills
- Knowledge of U.S. healthcare insurance and revenue cycle processes.
- Familiarity with commercial insurance, Medicare, and/or Medicaid.
- Knowledge of CPT, ICD-10, or basic medical terminology.
- Experience with EMR/EHR systems such as Epic, Cerner, Athena, or similar platforms.
- Familiarity with payer portals and insurance verification tools.
- Experience working with U.S.-based patients, providers, or insurance companies.
Key Performance Indicators
- Quality and accuracy
- Customer satisfaction
- First-contact resolution
- Average handling time
- Productivity and case completion
- Eligibility/benefits verification accuracy
- Prior authorization turnaround time
- Documentation compliance
- Attendance and schedule adherence
