What are the responsibilities and job description for the Member Experience Specialist position at WebTPA?
Job Description
Get To Know Us!
WebTPA, a GuideWell Company, is a healthcare third-party administrator with over 30 years of experience building unique benefit solutions and managing customized health plans.
What is your impact?
The Member Experience Specialist will work independently to improve the member experience for their dedicated clients. By engaging with members to identify and uncover needs and providing solutions that will enhance their health and wellness through phone and digital communication. They should proactively identify potential issues ensuring the organization is consistently providing exceptional member service. This function is office-based and resides within a customer focused "POD" or team. The POD includes team members from claims, customer service, analytics, and clinical. This integrated team's goal is to drive high quality, cost effective results for plan members and sponsors, with the ultimate goal of being a good steward of the plan's health care spend.
What Will You Be Doing
To support your wellbeing, comprehensive benefits are offered. As a WebTPA employee, you will have access to:
General Physical Demands
Get To Know Us!
WebTPA, a GuideWell Company, is a healthcare third-party administrator with over 30 years of experience building unique benefit solutions and managing customized health plans.
What is your impact?
The Member Experience Specialist will work independently to improve the member experience for their dedicated clients. By engaging with members to identify and uncover needs and providing solutions that will enhance their health and wellness through phone and digital communication. They should proactively identify potential issues ensuring the organization is consistently providing exceptional member service. This function is office-based and resides within a customer focused "POD" or team. The POD includes team members from claims, customer service, analytics, and clinical. This integrated team's goal is to drive high quality, cost effective results for plan members and sponsors, with the ultimate goal of being a good steward of the plan's health care spend.
What Will You Be Doing
- Relationship management: (20%)
- Responsible for designing member solutions for clients and internal stakeholders.
- Design and execute proactive member engagement outreach strategies (20%)
- Eligibility responsibility, managing and troubleshooting Client EDI files and ensuring eligibility implementation is finalized by established dates (15%)
- Serve internal members as concierge support: (15%)
- Initiate claims investigation, negotiate settlements, interpret medical records, respond to Department of Insurance complaints, and authorize payment to claimants and providers
- Serve as the immediate escalation resource for customer service reps and claims examiners
- Responsible for claims processing and adjudication, researching claims where applicable
- Provide member service: (15%)
- Inbound and Outbound proactive outreach to members, as determined by the MES utilizing client data and analytics
- Resolve member issues routed through member calls
- Triage and escalate member issues to the necessary department when appropriate
- Engage with members to ensure previous issues have been resolved in a timely manner
- Support members and providers to the best experience in addressing OON facility services, provider billing challenges
- Maintain good rapport with physicians, healthcare facilities, clients, providers and internal and external stakeholders
- Review and process insurance to verify medical necessities and coverage under policy guidelines (clinical edit logic) (5%)
- Utilize systems to track complaints and resolutions (5%)
- Responsible for basic POD reporting and analytics demonstrating POD level performance for clients (5%)
- 1 years related work experience.
- Related Bachelor’s degree or additional related equivalent work experience from an accredited university; preferably in Business, communications or experience working the medical insurance field
- Strong proficiency with Microsoft Office.
- Strong verbal and written communication skills; ability to tailor communications based on audience and business objectives.
- Comfortable working and communicating at very high levels across operational areas and working in cross-functional teams
- Must thrive in a team environment; team success will be heavily emphasized.
- Ability to prioritize or seek information on how to best prioritize projects.
- Project confidence, high energy, enthusiasm, and high regard for client advocacy and service
To support your wellbeing, comprehensive benefits are offered. As a WebTPA employee, you will have access to:
- Medical, dental, vision, life and global travel health insurance
- Income protection benefits: life insurance, Short- and long-term disability programs
- Leave programs to support personal circumstances.
- Retirement Savings Plan includes employer contribution and employer match
- Paid time off, volunteer time off, and 11 holidays
- Additional voluntary benefits available and a comprehensive wellness program
General Physical Demands
- Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.
