Homeoffice (Behavioral Health) Customer Service Representative bei Blue Shield of California Group

The following job summary will help you understand the candidates/people well suited to our Behavioral Health Call Center Team.

Job Summary:

Projected Start date: November 2025

Mandatory Training: Remote

As a Behavioral Health Customer Service Representative (CSR), you are in charge of upholding our mission of providing a service worthy of our family and friends. Our members look to you to help them navigate healthcare, providing empathy and advocacy.  You are empowered to provide members with peace of mind that their current issue is resolved and that none are on the horizon. 

Successful CSRs deliver an effortless customer experience by: 

• Taking the lead – our CSRs take ownership of members' issues, relieving members' stress while guiding them to a quick and easy resolution. 
• Identifying future problems – not only do our CSRs solve the current member concern but they actively identify and solve any lurking complications the member may encounter after their first interaction. 
• Sharing insights with peers and management – our positive team culture relies on open communication to continuously improve how our work gets done. 
• Having fun! – our work is important, but we don't take ourselves too seriously. We love helping others and have a fun community dedicated to doing so! 

You must also be:

• Available to work a scheduled 8-hour shift, which includes 2 scheduled breaks and a lunch period, also available to work occasional holidays as part of your regularly scheduled shift
• Maintain a high degree of patience and care for members who call into our centers with a question or a problem. 
• A good listener and answer the caller’s questions, but identify and provide answers to questions the member may not be aware they need to know
• Comfortable using a computer with 2 display monitors to allow you to navigate to multiple screens for information
• Comfortable using Excel spreadsheets to calculate member premiums for health insurance
• To multi-task using a computer; talking to the member, and entering member information into their online record

Your Work 
Responsibilities include: 

• Resolve incoming calls concerning member's eligibility, benefits, provider information, clinical and pharmacy needs 
• Compose routine and non-routine correspondence to answer benefits/provider inquiries in writing 
• Coordinate membership changes such as member's primary care physician
• Perform routine to mid-level inventory reduction (i.e., member inquiries, may initiate claim adjustments, respond to emails, etc.) 
• Review and analyze member claims for accuracy as well as member education on how benefits are applied
• Participate in quality and efficiency workgroups to continuously improve quality member/customer satisfaction as requested 
• Proactively analyze available programs, determine program eligibility and connect the Member to appropriate BSC vendors, Health Advocates, Social Workers, Pharmacy Techs, and Pharmacists. Verify the member is included in or targeted for any outreach or care gap programs and connect members to programs or services when appropriate. Engage members with their wellness plan options 
• Comprehensive resolution of pharmacy calls concerning benefits coverage, co-pays, formulary coverage, vacation overrides, and utilization management requirements 
• Provide prescription-related benefit coverage (e.g. explanation of coverage or benefit summary related): Provide prescription co-pays. Provide prescription formulary coverage information and utilization management requirements using web-posted printed formulary. Provide a brief description of coverage denial reasons and alternatives listed in the printed formulary. Perform prescription claim overrides 
• Provide deductible and max out of pocket information 
• Provide status of prior authorization requests 
• Assist members may when and how to appeal a coverage decision 
• Other duties as assigned 

Your Knowledge and Experience 

• Must reside in the state of CA, preferrable within a 50-mile radius of one of our office locations – El Dorado Hills, Lodi, Long Beach, Oakland, Rancho Cordova, Redding, San Diego, Woodland Hills, etc. 
• Requires a High School Diploma or GED, or equivalent 
• Typically, requires a minimum of 3 years experience specific to the above forementioned CSR success criteria 
• Flexibility in availability is required including hours and holidays, shifts are not guaranteed 
• Requires attending and completing training facilitated remotely
• Requires basic job knowledge of Microsoft Suite systems and the ability to use applications on a computer proficiently 
• Requires internet connection of 5Mbps (recommended 15Mbps) is required to maintain a stable connection to our Blue Shield of California network and systems
• Post-training, Requires private work location at their residence free from distractions and within 15 feet of their Wi-Fi modem

About Blue Shield of California

As of January 2025, Blue Shield of California became a subsidiary of Ascendiun. Ascendiun is a nonprofit corporate entity that is the parent to a family of organizations including Blue Shield of California and its subsidiary, Blue Shield of California Promise Health Plan; Altais, a clinical services company; and Stellarus, a company designed to scale healthcare solutions. Together, these organizations are referred to as the Ascendiun Family of Companies. 

At Blue Shield of California, our mission is to create a healthcare system worthy of our family and friends and sustainably affordable. We are transforming health care in a way that genuinely serves our nonprofit mission by lowering costs, improving quality, and enhancing the member and physician experience. 

To achieve our mission, we foster an environment where all employees can thrive and contribute fully to address the needs of the various communities we serve. We are committed to creating and maintaining a supportive workplace that upholds our values and advances our goals.

Blue Shield is a U.S. News Best Company to work for, a Deloitte U.S. Best Managed Company and a Top 100 Inspiring Workplace. We were recognized by Fair360 as a Top Regional Company, and one of the 50 most community-minded companies in the United States by Points of Light. Here at Blue Shield, we strive to make a positive change across our industry and communities – join us!  

Our Values: 

• Honest. We hold ourselves to the highest ethical and integrity standards. We build trust by doing what we say we're going to do and by acknowledging and correcting where we fall short. 
• Human. We strive to listen and communicate effectively, showing empathy by understanding others' perspectives.
• Courageous. We stand up for what we believe in and are committed to the hard work necessary to achieve our ambitious goals. 

Our Workplace Model:

At Blue Shield of California and the Ascendiun Family of Companies, we believe in fostering a workplace environment that balances purposeful in-person collaboration with flexibility. As we continue to evolve our workplace model, our focus remains on creating spaces where our people can connect with purpose – whether working in the office or through a hybrid approach – by providing clear expectations while respecting the diverse needs of our workforce.

Two Ways of Working:

• Hybrid (Default): Work from a business unit-approved office at least two (2) times per month (for roles below Director-level) or once per week (for Director-level roles and above). Exceptions:

o   Member-facing and approved out-of-state roles remain remote.

o   Employees living more than 50 miles from their assigned offices are expected to work with their managers on a plan for periodic office visits.

o   For employees with medical conditions that may impact their ability to work in-office, we are committed to engaging in an interactive process and providing reasonable accommodations to ensure their work environment is conducive to their success and well-being.

• On-Site: Work from a business unit-approved office an average of four (4) or more days a week.

Physical Requirements:

Office Environment - roles involving part to full time schedule in Office Environment. Based in our physical offices and work from home office/deskwork - Activity level: Sedentary, frequency most of work day.

Please click here for further physical requirement detail. 

Equal Employment Opportunity:

External hires must pass a background check/drug screen. Qualified applicants with arrest records and/or conviction records will be considered for employment in a manner consistent with Federal, State and local laws, including but not limited to the San Francisco Fair Chance Ordinance. All qualified applicants will receive consideration for employment without regards to race, color, religion, sex, national origin, sexual orientation, gender identity, protected veteran status or disability status and any other classification protected by Federal, State and local laws.