Member Services Representative

Job Description

Job Description

To support the Director of Member Services in providing a single point of contact for questions, problem solving, and access to care, for all involved in members’ care.  To provide accurate, prompt, and courteous service in response to written and telephonic inquiries, from Members, Members’ Care-Givers, Primary or Interdisciplinary Care Team Members, Pharmacies, and Vendors. To facilitate quality member care and service delivery by responding to every inquiry immediately and directly, when possible, or by collaborating with our Interdisciplinary or Primary Care Teams, Clinical Staff, and others involved in providing care for our members.

Essential Job Functions :

• Respond to and answer all member and provider inquiries in a courteous, responsive, comprehensive, effective, and accurate manner following all departmental and organizational policies and procedures.
• Thoroughly document all member related interactions into system for purpose of accurate tracking and analysis.
• Coordinate with various departments to member customer requests and questions are handled appropriately and in a timely manner.
• Provide translation and interpretation when requested / approved by supervisor.
• Daily tasks include : ongoing incoming and outgoing phone calls; ongoing incoming and outgoing email; ongoing use of member database; processing paper mail; and processing faxes.
• Respond to and resolve, on the first call, member service inquires and issues by identifying the topic and type of assistance the caller needs such as benefits, eligibility and claims, and correspondence.
• Complete Outbound Enrollment Verification (OEV) calls to new members and ensure compliance with CMS standards.
• Proactively contact established members for continued education and retention
• Participate as part of a team conducting and / or supporting outreach to members regarding benefits and eligibility requirements.
• Initiate proactive outreach to members as needed, which may involve welcoming new members to our health plans, addressing gaps in care, reviewing coverage, and referring & enrolling them to internal specialists and programs based on their needs and eligibility
• Contact care providers (doctor’s offices) on behalf of the member to assist with appointment scheduling or connections with internal specialists for assistance
• Demonstrated ability to listen skillfully, collect relevant information, build rapport and respond to members in a compassionate manner
• Proficient conflict management skills to resolve issues in a stressful situation

Qualifications :

Note :   This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s).  Duties described are not to be interpreted as being all-inclusive or specific to any individual team member.

No Third Party Agencies or Submissions Will Be Accepted.

Our company is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. DFWP

Opportunities posted here do not create any implied or express employment contract between you and our company / our clients and can be changed at our discretion and / or the discretion of our clients. Any and all information may change without notice. We reserve the right to solely determine applicant suitability. By your submission you agree to all terms herein.

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