A customer calls, frustrated because their recent claim was denied. How do you handle the call?
RoleCustomer Service Representative
DifficultyMedium
TopicCommunication
Asked at
Why This Is Asked
This is not a verbatim reported question, but it reflects the healthcare-specific challenges Optum CSRs face daily, testing problem-solving, communication, and composure.
General Approach
Demonstrate the ability to de-escalate, educate the customer, and provide actionable steps. Balance empathy with efficiency.
General Answer
Let the customer explain their frustration fully before responding. Pull up the claim and explain the specific reason for denial in plain language, referencing the actual policy provision or missing documentation rather than a generic "it's policy." Check whether it's something correctable, like a coding error or missing paperwork, and if so, walk them through exactly what needs to be resubmitted and by when. If the denial is correct as it stands, explain that clearly and point them to the plan's formal appeal or grievance process, since most health plans have one, without promising an outcome you can't guarantee. Document the call and any follow-up steps you commit to.
PH Interview Gotcha
Using jargon like 'UCR' or 'pre-authorization' without explaining, or saying 'Wala na po tayong magagawa dyan' (There's nothing we can do). Instead, explain benefits in simple terms and always offer alternatives.
Sample STAR Answer▾
S
Situation
I took a call from a policyholder who was visibly upset because her recent outpatient procedure was not covered by insurance.
T
Task
My goal was to clarify the denial reason, explore possible solutions, and calm the customer.
A
Action
First, I let her vent without interrupting, then I acknowledged her frustration sincerely. I pulled up her policy and, in plain language, explained that the specific clinic was out-of-network. I informed her that she could file an appeal and offered to email the appeal form along with a list of in-network providers for future needs.
R
Result
She appreciated the clear explanation and felt empowered to take the next steps. The call ended on a positive note, and she thanked me for my patience and guidance.
Key Takeaway
Customers value transparency and a clear path forward more than just a sympathetic ear.
Attempt Your Answer
Write your own answer, then get instant AI feedback graded against:
- •STAR Structure
- •Specificity & Numbers
- •Ownership Language
- •PH Workplace Context
Get AI feedback on your answer — free.
3 free AI-graded answers + 1 free mock interview, no card needed.
Sign Up FreeAlready have an account? Log in
Share Your Answer (0)
Sort
Sign in to join the conversation.
No answers shared yet — be the first to show how you'd approach this.