Role overview

Qualifications

High school diploma or GED required; associate or bachelor's degree preferred
2+ years of experience in health benefits customer service, claims, or member services
Working knowledge of claims processing, eligibility, and benefit structures
Proficiency with CRM/ticketing systems (e.g., Zendesk) and standard office software

Responsibilities

Resolve second-level escalations beyond first-line CSR capability across claims, eligibility, benefits, and billing inquiries
Investigate issues thoroughly, document findings, and record all activity in the centralized escalation tracker
Determine root cause where possible; when the issue is an education matter, work directly with the member to provide education
Assist in escalated call audits and tracking currently being done by the Customer Service Director

Key facts

Remote from: United States
Full time
Mid-level (2-5 years)
50 - 50K yearly
English

Hard skills

Issue Management Internal Documentation Medical Coding Billing Escalation Management

Other skills

Customer Service
Communication
Problem Solving
Teamwork
Time Management

About the company

Point C

Insurance

Point C is a National Third-Party Administrator (TPA) with local market presence that delivers customized self-funded benefit programs. Our commitment and partnership means thinking beyond the typical solutions in the market – to do more for your clients – and take you beyond the standard “Point A to Point B.” Our TPA partners have decades of experience curating custom healthcare plans that simultaneously reduce healthcare spend for employers and help employees get the quality care they need.

Company details

IndustryInsurance

Company size201 - 500

Links

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Job description

Point C is a National third-party administrator (TPA) with local market presence that delivers customized self-funded benefit programs. Our commitment and partnership means thinking beyond the typical solutions in the market – to do more for clients – and take them beyond the standard “Point A to Point B.” We have researched the most effective cost containment strategies and are driving down the cost of plans with innovative solutions such as, network and payment integrity, pharmacy benefits and care management. There are many companies with a mission. We are a mission with a company.

Point C is seeking a Service Resolution Specialist (SRS) to join our Customer Service team, supporting the Rapid Response Team and reporting to the Customer Service Director. The SRS is the first dedicated level of service resolution within Customer Service, handling second-level escalations that front-line Customer Service Representatives cannot resolve. The SRS investigates and resolves routine and standard client and member issues quickly and accurately and escalates more technically complex matters to an Employer Service Representative. Over time, the SRS is intended to serve as the direct initial point of contact for clients on standard items.

Primary Responsibilities:

Resolve second-level escalations beyond first-line CSR capability across claims, eligibility, benefits, and billing inquiries
Investigate issues thoroughly, document findings, and record all activity in the centralized escalation tracker
Determine root cause where possible; when the issue is an education matter, work directly with the member to provide education
Assist in escalated call audits and tracking currently being done by the Customer Service Director
Escalate to an ESR when an issue is technically complex or requires deeper expertise, providing a clear and documented handoff
Take approved immediate actions within authority and route “send-on” items to the appropriate team
Meet acknowledgment, response, and resolution SLAs based on issue severity
Coordinate all client-facing responses through Account Management and the RRT; avoid conflicting or untracked communication
Flag recurring issues and emerging patterns to the RRT to support trend identification and root cause analysis

Qualifications:

High school diploma or GED required; associate or bachelor's degree preferred
2+ years of experience in health benefits customer service, claims, or member services
Working knowledge of claims processing, eligibility, and benefit structures
Proficiency with CRM/ticketing systems (e.g., Zendesk) and standard office software
Strong written and verbal communication skills with a customer-service orientation
Experience in a third-party administrator (TPA), health plan, or PBM environment is a plus
Familiarity with medical coding and billing fundamentals is a plus
Prior escalation, second-level, or issue-resolution support experience is a plus

Individual compensation will be commensurate with the candidate's experience and qualifications. Certain roles may be eligible for additional compensation, including bonuses, and merit increases. Additionally, certain roles have the opportunity to receive sales commissions that are based on the terms of the sales commission plan applicable to the role.

Pay Transparency

$45,000—$50,000 USD

Benefits:

Comprehensive medical, dental, vision, and life insurance coverage
401(k) retirement plan with employer match
Health Savings Account (HSA) & Flexible Spending Accounts (FSAs)
Paid time off (PTO) and disability leave
Employee Assistance Program (EAP)

Equal Employment Opportunity: At Point C Health, we know we are better together. We value, respect, and protect the uniqueness each of us brings. Innovation flourishes by including all voices and makes our business—and our society—stronger. Point C Health is an equal opportunity employer and we are committed to providing equal opportunity in all of our employment practices, including selection, hiring, performance management, promotion, transfer, compensation, benefits, education, training, social, and recreational activities to all persons regardless of race, religious creed, color, national origin, ancestry, physical disability, mental disability, genetic information, pregnancy, marital status, sex, gender, gender identity, gender expression, age, sexual orientation, and military and veteran status, or any other protected status protected by local, state or federal law.

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