Member Service Representative

Description

POSITION SUMMARY:
The Member Service Representative is the primary and initial point of contact for insured members and healthcare providers. The Member Service Representative is responsible for assisting members in understanding their health plan, claim status and answering any questions regarding their benefits, as well as accurately quoting benefits and educating providers of the health plan.

ESSENTIAL DUTIES AND RESPONSIBILITIES:
Provides compassionate and dedicated support to ensure the member experience is in line with Vitori Health values.
Educates and assists members on various elements of benefit plan information.
Provides the caller with related information to answer the unasked questions, e.g., additional plan details, benefit plan details, member self-service tools, claims.
Triages claims and escalate issues as appropriate through the system for grievances and appeals.
Assists members in finding accepting providers and facilities that address their needs.
Coordinate with Member Advocate for issues in relation to provider access escalations.
Educates and gains acceptance with providers and facilities when they have questions about the health plan.
Sets expectations and consistently follows up with communications to the member from ticket initiation to closure.
Responds and resolves inquiries on the first call by identifying the topic and type of assistance the caller needs utilizing all resources available.
References automated job aid tools via the computer to identify appropriate procedures when needed and research relevant rules, regulations, or procedures.
Accurately documents, researches, and resolves all inquiries by ensuring documentation is clear and complete.
Meets or exceeds individual and departmental quality standards / achieves performance goals.
Adheres to, keeps current on, and utilizes all company guidelines, policies and procedures.

Soft Skills:
Demonstrated ability to quickly build rapport and respond to members in a compassionate manner by identifying and exceeding member expectations (responding in respectful, timely manner, consistently meeting commitments).
Demonstrated ability to listen skillfully, collect relevant information, determine immediate requests, and identify the current and future needs of the member.
Proficient problem-solving approach to quickly assess current state and formulate recommendations.

Proficient in translating healthcare related jargon and complex processes into simple, step-by-step instructions members can understand and act upon.
Flexibility to customize approach to meet all types of member communication styles and personalities.
Proficient conflict management skills including the ability to resolve issues in a stressful situation and demonstrating personal resilience.

Qualifications

QUALIFICATIONS:
The Member Service Representative must be highly motivated and a self-starter and demonstrate reliable attendance. This individual needs to possess strong member service skills, excellent written and verbal communication skills, strong inter-personal and problem-solving skills, convey compassion and be detail oriented. The individual must be able to manage time-sensitive projects and multiple priorities and be comfortable with activities that vary from day-to-day. To perform the position, an individual must be able to satisfactorily perform each essential duty. The requirements listed are representative of the knowledge, skill, and/or ability required.

EDUCATION AND/OR EXPERIENCE:
It is required that individuals have completed a bachelor’s degree or have equivalent job experience. Minimum 2 years prior experience with health plans, benefit plans, claims and/or healthcare required. Minimum 2 years of experience in member service in a healthcare environment. Minimum one year experience working in Microsoft Office, specifically Excel, Outlook, Word, and Zendesk. Multilingual preferred but not required.
Individuals should have proven experience working in benefits or similar capacity where responsibility included member support, insurance plan education, medical billing and/or scheduling and maintaining working relationships with various partners in the benefits industry.

COMPETENCIES:
The Member Service Representative should continue to develop the following competencies with an attitude of being a lifelong learner in the fields of employee benefits, insurance, and business:

Client and Personal Service Knowledge of principles and processes for providing client and personal services. This includes client needs assessment, meeting quality standards for services, and evaluation of client satisfaction.
Fluency of Ideas The ability to produce several ideas about a topic (the number of ideas is important, not their quality, correctness, and creativity).
Active Listening Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times.
Problem Sensitivity The ability to tell when something is wrong or is likely to go wrong. It does not involve solving the problem, only recognizing there is a problem.
Establishing and Maintaining Interpersonal Relationships Developing constructive and cooperative working relationships with others and maintaining them over time.
Communicating with Internal and External Partners Providing information to partners within and outside the organization by telephone, in written form, e-mail, and in person.
Organization Prioritizing workflows based upon client needs, deadlines (internal and external) and available resources; being capable of managing multiple projects at one time.
Critical Thinking Using logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, and approaches to problems.
Updating and Using Relevant Knowledge Keeping up-to-date technically and applying new knowledge to your job.
Written Expression The ability to communicate information and ideas in writing so others will understand.
Written Comprehension The ability to read and understand information and ideas presented in writing.
Oral Expression The ability to communicate information and ideas verbally so others will understand.
Oral Comprehension The ability to listen to and understand information and ideas presented verbally.
Organizing, Planning, and Prioritizing Work Developing specific goals and plans to prioritize, organize, and accomplish your work.

COMPUTER SKILLS:
To perform this job successfully, an individual should have advanced proficiency in all Microsoft Office products and be able to learn new systems within a reasonable time.

PHYSICAL DEMANDS:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.
While performing the duties of this job, the employee is regularly required to stand, walk, use hands and fingers, talk, and hear. The employee is frequently required to sit and reach with hands and arms. The employee is occasionally required to climb or balance and stoop, kneel, crouch or crawl. The employee must regularly lift and/or move up to ten pounds and occasionally lift and/or move twenty-five pounds or more.
Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception and ability to adjust focus.

WORK ENVIRONMENT:
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. The employee will work both in an office environment and remotely from home during typical office hours with occasional overtime. Vitori membership is nationwide therefore earlier or later hours may be required to accommodate varying Time zones. The office environment has moderate temperatures and minimal noise levels. When working remotely the employee must have a quiet, office-like work environment suitable for phone and web calls, and strictly adhere to HIPAA and privacy regulations. Occasional travel may be required.

ADDITIONAL COMMENTS:
This job description is not intended to be a complete list of all responsibilities, duties or skills required for the job and is subject to review and change at any time, with or without notice, in accordance with the needs of Vitori Health LLC. Since no job description can detail all the duties and responsibilities that may be required from time to time in the performance of a job, duties and responsibilities that may be inherent in a job, reasonably required for its performance, or required due to the changing nature of the job shall also be considered part of the jobholder’s responsibility.