Member Services Representative (HMO)

SUMMARY

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

1. Professionally handles a high volume of complex calls and may also process correspondence (mail, faxes or written letters).
2. 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.
3. 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.
4. Contributes to meeting or exceeding CMS call center metrics and Call center goals.
5. Follows up with caller to provide response or resolution steps as needed.
6. Clearly documents incoming and outgoing call reasons and dispositions in the call center system
7. 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
8. Wears a complete uniform or professional business attire (dependendt on job duty) and keeps a clean and neat appearance during working hours.
9. Demonstrates courtesy and politeness to patients, visitors, callers and other employees.
10. Maintains open channels of communication with center administration and other company departments; Answers all inquiries in a professional and courteous manner.
11. Participates in training and in-service education as required.
12. Participates in department, clinic and other meetings as requested.
13. Complies with the organizaion's policies and procedures and maintains confidentiality in accordance with state and federal laws.
14. Participates in special projects and performs other duties as assigned.

QUALIFICATIONS

Minimum one (1) year of experience working in a call center in insurance managed care, preferably a Medicare HMO.

• 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 communicate verbally.
• Computer Skills: Proficient in Microsoft Office Applications.
• Experience working with vulnerable populaitons
• Demonstrated ability to quickly build rapport and respond to customers in a compassionate manner by identifying and exceeding customer 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
• Ability to work any of our 8-hour shift schedules during our normal business hours of 8:00am - 8:00pm EST

EDUCATION

High School Diploma

LANGUAGE SKILLS

Bilingual English/Spanish fluency.

CERTIFICATES, LICENSES, REGISTRATIONS

N/A

PHYSICAL DEMANDS/WORK ENVIRONMENT

Work schedule is approximate and hours/days may change based on company needs. All full-time employees are required to complete forty (40) hours per week as scheduled, including on weekends and holidays. Position requires the ability to work extended hours when necessary.

The physical demands and work environment characteristics described herein are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

This work requires the following physical activities: climbing, bending, stooping, kneeling, twisting, reaching, sitting, standing, walking, lifting, finger dexterity, grasping, repetitive motions, talking, hearing and visual acuity. The work is performed indoors.