Member Services Rep

The Member Services Representative Receives incoming calls from prospective members, current members and representatives. Listens to the questions and/or concerns and provides clear and concise responses that provide for first call resolution.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Professionally handles a high volume of complex calls and may also process correspondence (mail, faxes or written letters).
• Researches accounts, claim history or benefits to identify issues and resolution steps. Identifies the correct department to assist with timely and accurate resolution as needed. Able to explain to the caller any action that is required in order to resolve the inquiry or concern.
• Identifies complaints (grievances), requests for coverage determinations or appeals, and possible fraud, waste or abuse to forward to the correct department for research and resolution.
• Contributes to meeting or exceeding CMS call center metrics and Call center goals.
• Follows up with caller to provide response or resolution steps as needed.
• Clearly documents incoming and outgoing call reasons and dispositions in the call center system.
• Developes and maintains positive customer relations and coordinates with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner
• Wears a complete uniform or professional business attire (dependendt on job duty) and keeps a clean and neat appearance during working hours.

QUALIFICATIONS

• Basic understanding and ability to apply Centers for Medicare and Medicaid (CMS) regulatory requirements and standard operating procedures.
• Exception problem solving skills.
• Must be able to effectively communicateverbally.
• Computer Skills:Proficient in Microsoft Office Applications.

WORK EXPERIENCE

• Minimum one (1) yearof experienceworking in a call center in insurance managed care, preferably a Medicare HMO.

LANGUAGE SKILLS

• Bilingual English/Spanish fluency.