Job Description
Customer Operations Specialist (Tier 1 - 3 Escalations) Must live in TX, FL, AZ or OH
Pay: $20.00 - $25.00/hr
Location: Remote (Must live in TX, FL, AZ, or OH)
Hours: Mon-Sat, 8:00 AM - 7:30 PM (Schedules set 1 month in advance; shift flexibility and weekend work required).
Role Overview We are hiring detail-oriented specialists to handle customer inquiries, perform root-cause investigations, and manage regulatory escalations across three operational tiers.
Key Responsibilities
- Tier 1 (Front-Line): Provide high-volume first-contact resolution (FCR) for routine member/provider inquiries via phone, chat, and email following SOPs.
- Metrics: FCR, Quality Score, Average Handle Time (AHT), Schedule Adherence.
- Tier 2 (Complex Operations): Deep-dive into complex multi-touch issues, claims mismatches, and billing errors with internal teams (Claims, Billing, Network).
- Metrics: SLA Compliance, Resolution Time, Backlog Control, Repeat Contact Reduction.
- Tier 3 (Regulatory & Compliance): Handle high-sensitivity complaints, appeals, and grievances. Partner with executive leadership and regulatory agencies (CMS, HICS, DOI, BBB) to draft legally defensible, audit-ready responses.
- Metrics: Response Timeliness, Audit Readiness, Leadership Acceptance Rate.
Qualifications
- Education: High School Diploma or GED required (Associate/Bachelor's preferred).
- Experience:
- 1+ years in high-volume customer service (Healthcare/Insurance preferred), OR
- 2+ years in healthcare/insurance operations, billing, or claims, OR
- 3+ years in healthcare appeals, grievances, regulatory ops, or compliance.
- Knowledge: Familiarity with CMS audits, Medicare Part A & B, Medicaid, and ACA coverage.
- Requirements: Proven experience handling escalated cases. Must pass an unassisted knowledge test (no AI or outside resources permitted). Must reside in TX, FL, AZ, or OH.
salary: $20 - $25 per hour
shift: First
work hours: 8 AM - 7:30 PM
education: High School
Responsibilities
- Deep investigation of complex, multi-touch, or cross-functional issues.
- Internal departments (Billing, Claims, Network)and escalated customers.
- Root cause analysis of billing errors, claims mismatches, and process breakdowns.
- Case resolution time, SLA compliance, Backlog control, Repeat contact reduction.
The essential functions of this role include:
Skills
- Claims Processing
- Research
- Regulatory Compliance - Other
- High Volume
- Billing
- Claims
- appeals
- Call Center
Qualifications
- Years of experience: 2 years
- Experience level: Experienced
Randstad is a world leader in matching great people with great companies. Our experienced agents will listen carefully to your employment needs and then work diligently to match your skills and qualifications to the right job and company. Whether you're looking for temporary, temporary-to-permanent or permanent opportunities, no one works harder for you than Randstad.
Equal Opportunity Employer: Race, Color, Religion, Sex, Sexual Orientation, Gender Identity, National Origin, Age, Genetic Information, Disability, Protected Veteran Status, or any other legally protected group status.
At Randstad, we welcome people of all abilities and want to ensure that our hiring and interview process meets the needs of all applicants. If you require a reasonable accommodation to make your application or interview experience a great one, please contact HRsupport@randstadusa.com.
Pay offered to a successful candidate will be based on several factors including the candidate's education, work experience, work location, specific job duties, certifications, etc. In addition, Randstad offers a comprehensive benefits package, including: medical, prescription, dental, vision, AD&D, and life insurance offerings, short-term disability, and a 401K plan (all benefits are based on eligibility).
This posting is open for thirty (30) days.
It is unlawful in Massachusetts to require or administer a lie detector test as a condition of employment or continued employment. An employer who violates this law shall be subject to criminal penalties and civil liability.
Job Tags
Hourly pay, Permanent employment, Temporary work, Work experience placement, Live in, Remote work, Shift work