Role Overview The IFP (Individual & Family Plans) Customer Service Representative (CSR) serves as the frontline support, account manager, and primary touchpoint for the agency’s individual and family health insurance book of business, encompassing both Covered California and Off-Exchange plans.

This role focuses on resolving member inquiries, maintaining active eligibility status, managing carrier and state-mandated documentation requests, and driving early-stage retention. The IFP CSR ensures high client satisfaction through empathetic service while managing rigorous administrative workflows within Salesforce, carrier portals, and the Covered California system.

Key Performance Indicators (KPIs)

- First-Contact Resolution (FCR): Efficiently resolve client inquiries regarding benefits, billing, or network access on the initial call to optimize the customer experience.
- Document Verification Rate: Successfully collect and upload 100% of Covered California or carrier-mandated eligibility documents within the strict deadlines to prevent policy termination.
- Retention Rate: Identify at-risk clients (those requesting cancellation or premium reductions), execute core saving protocols, and seamlessly triage accounts to preserve the agency's book of business.

Key Responsibilities 1. Customer Care, Advocacy & Account Maintenance

- Inbound Inquiry Resolution: Handle a high volume of inbound calls from active clients, answering questions regarding plan coverage, medical benefits, copays, deductibles, and dental/vision riders for both exchange and off-exchange policies.
- Complex Account Updates: Guide and assist clients through life-change reporting on the Covered California portal or directly with carriers, including updating household income, changing family size, reporting address changes, or navigating immigration/citizenship data updates.
- Provider Network Support: Help clients verify if their preferred doctors, specialists, or local medical groups remain active within their selected insurance company's HMO/PPO network.

2. Retention Operations, Document Tracking & Outbound Care

- Eligibility Documentation Compliance: Proactively contact clients via outbound campaigns to request, collect, and upload the verification documents requested by Covered California or private carriers (e.g., proof of income, citizenship, lawful presence) to secure their active status and avoid subsidy or plan loss.
- Financial Account Protection: Process monthly premium payments, set up automatic billing (EFT/Autopay), and execute targeted outbound calls to remind clients of late or pending payments to prevent policy lapse.
- Welcome & Onboarding Campaigns: Conduct proactive courtesy/welcome calls to new members entering California Plans, reinforcing who their assigned agent is, confirming plan activation, and verifying overall satisfaction.
- Strategic Retention Triaging: Constantly educate clients on the value of staying insured and avoiding tax penalties. If a client insists on canceling due to affordability or a move to another agency, evaluate basic parameters and immediately route the case to the Retention & Recovery Specialist for plan restructuring.

3. Sales Support & Pipeline Administration

- Lead Generation & Cross-Selling Support: Identify expansion opportunities during service interactions (e.g., adding a spouse, attaching a dental/vision plan) and route high-intent leads to the IFP/CCA Sales Producers.
- Application Integrity Tracking: Review newly submitted applications to ensure they are fully approved by the carrier and Covered California, correcting any pending administrative errors.

4. CRM Integrity & Workflow Productivity

- Salesforce Data Discipline:



Maintain meticulous, real-time records of every customer interaction. Log highly detailed call notes, complaints, changes made, and securely upload all supporting documentation.
- Workflow Optimization: Prioritize incoming queue calls as the absolute highest operational focus. Utilize downtime between calls to systematically process and clear the internal California Plans pending workflow checklists.

Required Skills & Qualifications

- Bilingual Fluency: 100% fluent in written and spoken English and Spanish, with the ability to translate complex ACA and private health insurance concepts into clear, simple terms.
- IFP Enrollment Portal Expertise: Hands-on experience navigating the Covered California agent portal as well as private carrier off-exchange quoting/administration platforms.
- Advanced Call Control: Exceptional capability to remain calm, patient, and highly professional when handling stressed, confused, or escalated callers.
- Systems Familiarity: Proven experience utilizing enterprise CRM software (Salesforce) and operating multi-line cloud phone systems under high-volume conditions.

Adecuado Personality Traits

- Patient and Empathetic: Possesses a genuine desire to help families navigate their healthcare options with warmth and understanding.
- Organized and Detail-Oriented: Meticulous about state and carrier deadlines, document processing, and data accuracy to avoid client coverage gaps.
- Team-First Collaborator: Thrives when working closely with sales producers, management, and fellow CSRs to maintain a positive and efficient office environment.

PERFORMANCE & EVALUATION MATRIX Operational Context: Performance evaluations are based on an 8-hour shift, which includes a 20-minute daily morning meeting and two 10-minute rest breaks. This leaves a net total of 7 hours and 20 minutes of active desk availability per day.

1. Productivity, Volume & Workload Metrics

Metric

Target Standard

Tracking Method

Daily Productivity Baseline

Minimum of 56 tracked interactions per standard shift.

Salesforce Activity Logs

Hourly Performance Pace

Averages 7.6 interactions per active hour of desk availability.

Salesforce Timestamp vs. Logged Shift

- Eligible Channels: Combined system visibility across walk-ins, inbound calls, outbound calls, sent emails, text messages, and Covered California broker portal escalations (each action counts as 1 interaction).
- Data Integrity Requirement: Interactions only count toward the daily target if they include comprehensive real-time notes logged in Salesforce. Short, undocumented system clicks or "ghost dials" are automatically excluded.
- Inbound % (Workload Balance): Measures the percentage of incoming customer service calls answered. Every agent is expected to handle an equal, fair share of the total monthly inbound call volume (e.g., an even 20% split for a 6-agent office, each one) to ensure balanced team coverage.

2. Campaign, Retention & State Compliance List Completion & Outbound Integrity (The Priority Critical Objective)

- Campaign Target: Ensures 100% completion of all assigned monthly outreach lists (Late Payments, Welcome to Cal Plans, etc.) before the end-of-month deadline.
- Call Quality Minimum:



A client profile on an outreach list is only considered "Processed & Completed" if it results in a direct resolution OR has at least 3 documented contact attempts (combination of calls, texts, or emails) made on separate days.

Document Verification & State Compliance

- Mandate Deadline Target: Achieves a 100% success rate in collecting, verifying, and uploading Covered California or carrier-mandated eligibility documents (e.g., Proof of Income, Lawful Presence) before the state-specified deadline to avoid subsidy loss or plan termination.

3. Service Quality & Customer ExperienceCall Quality & Performance Standard

- Audit Benchmarks: Achieves an average quality score of 90% or higher across monthly supervisor evaluations based on call audits.
- Compliance (AHIP) - [CRITICAL COMPONENT]: Zero-tolerance for compliance omissions. Agents must explicitly state the call recording disclaimer and complete full client identity verification on every single interaction.
- First-Contact Resolution (FCR): Focuses on resolving billing, network, or benefit issues immediately. Performance is tracked by monitoring and minimizing the volume of open cases left pending for follow-up in Salesforce.
- Retention Protocols: Before routing an at-risk client to the Retention & Recovery Specialist, the CSR must proactively present at least 2 affordability or plan-restructuring alternatives (e.g., carrier downgrades, subsidy recalculations, premium adjustments).

Client Evaluation

- Survey Requirements: Consistently requests feedback after every service interaction, aiming for a minimum of 10 completed reviews per month.
- Quality Score Target: Maintains an overall satisfaction rating of 9 out of 10 stars (or 90%) across all received monthly evaluations.

4. Professionalism & Team DisciplinePunctuality & Attendance

- Attendance Standard: Evaluated based on total scheduled workdays per month. If a personal matter requires an agent to work fewer than 6 hours of their shift, a full day off must be requested in advance to avoid overburdening team coverage.
- Punctuality Grace Period: Shift starts strictly at 9:00 AM. Any arrival recorded at 9:06 AM or later is flagged as late.
- Excused Absences & Delays: Absences are only contractually excused with a valid medical note.
- Planned Departures/Arrivals: Late arrivals or early departures for personal matters will only be excused from scoring penalties if requested and approved at least 24 hours in advance. Same-day notices will negatively affect the evaluation.

Professional Appearance & Dress Code

- Standard Policy: The dress code is office casual. If you have California Plans branded shirts, you may wear them with black or dark blue pants. A clean, professional appearance must be maintained at all times.
- Casual Fridays: On Fridays, neat blue jeans are allowed.
- Banned Attire (Do Not Wear): Acid-washed or faded jeans, torn or ripped clothing, shorts, miniskirts, athletic tennis shoes (unless solid black and discreet), see-through/revealing clothes, and tube tops.

System & CRM Discipline (Salesforce, ADP, Phone System)

- Tool Compliance: Company platforms, local networks, and hardware must be used strictly for professional, work-related purposes.
- Salesforce Data Integrity: Meticulous, real-time logging is mandatory. Every interaction must contain detailed call notes, specific changes made, clear case updates, and secured document attachments. Time tracking must be accurately punched daily via both Salesforce and ADP.

Sueldo: $15,000.00 al mes

Beneficios

- Trabajo desde casa

Pregunta(s) de postulación:
- ¿Has trabajado con Zoom, Gohighlevel?

Experiencia:
- Atención a clientes: 1 año (Deseable)

Idioma:
- Inglés (Deseable)

Lugar de trabajo: Empleo remoto

📌 Bilingual Customer Service Representative (Jalisco)
🏢 Roaa Servimex
📍 Jalisco