The Member Services Representative I
This is an entry level position which requires the ability to work as a team player and with external contacts, make sound judgements based on analysis of information, be an effective communicator, and balance advocacy for the member with the policies of the health plan. The MSR provides courteous professional and accurate responses to incoming inquiries regarding network, plan benefits, eligibility, authorizations, plan guidelines and policies and procedures, as well as claims and pharmacy issues.
Principle Duties and Responsibilities
- Serve as the primary contact for members, providers and others for questions related to claims, benefits, member eligibility and other questions our company.
- Respond to and resolve member service inquiries and issues by identifying the topic and type of assistance the caller needs such as benefits, eligibility, claims, behavioral health, and care coordination.
- Answer incoming calls, emails, and other requests for assistance in a timely manner in accordance to departmental performance targets and provides excellent customer service while doing so. May include assisting members in person.
- Recognize and understand the difference between calls that require quick resolutions and calls which will require follow-up and handle each them appropriately.
- Accurately document all calls/contacts as required by department standards via the Customer Relationship Management (CRM) system.
- Interface with Claims, Enrollment, IT, Network Management, Pharmacy, Authorizations and other internal departments to provide Service Excellence to our members.
- Help guide and educate members about the fundamentals and benefits of managed health care topics.
- Assist members in navigating our website, the Member Portal, and other health care partner online resources and websites to encourage/reassure them to use self-service tools that are available.
- Manage any issues through to resolution on behalf of the member; either on a single call or through comprehensive and timely follow-up.
- Research complex issues across multiple databases and work with support resources to resolve member issues and/or partner with others to resolve escalated issues. Provide education and status on previously submitted pre-authorizations or pre-determination requests for both medical and pharmaceutical benefits.
- Maintain a professional level of service to members always.
- Maintain confidentiality of information always.
- Accurately document and monitor for resolution all Claims, Enrollment, Network Management, Pharmacy, Authorization matters and other related issues.
- Conduct telephonic member outreach regarding Medi-Cal benefits and services. Establish and maintain internal and external contacts.
- Contacts: Receive, manage, and document telephone calls, emails, and other sources of contacts from members, potential members, and providers, and explain health plan benefits and plan rules. Describe the types of services the we offer to the Member within the managed care system. Provide clarification about issues regarding patient and physician rights and how the plan operates.
- Conflict resolution: Resolve member problems/conflicts by convening with other departmental staff as needed.
- Member communications: Create and/or mail appropriate member materials and communications as needed.
- Computer: Perform ongoing data entry which assists in the maintenance of the Member Services department database to ensure data integrity.
- Comply with the organization's Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.
- Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
Education or Training Equivalent To:
- Two years of college or equivalent office work, customer service work in call center environment.
- The ability to speak, write, read and understand-bilingual: Spanish/English
- A bilingual proficiency exam will be administered to ensure the candidate possesses the appropriate skill level to meet requirements. The successful candidate must score 70% or higher to be considered proficient.
- Minimum two years of direct customer service experience.
- Call center experience and managed care experience a plus.
- Experience determining eligibility for financial assistance, insurance benefits, unemployment and/or other social services programs.
- Demonstrated knowledge expert of AAH Member Services policies and procedures
- Demonstrated track record of schedule adherence (punctuality and attendance), including consistent use of the company's time tracking solution to track working hours
- Consistent record of high quality of work as demonstrated through call and documentation auditing, appropriate Call Disposition coding, as well as an overall acceptable monthly Member Satisfaction Survey result as assessed by Member Services Quality Specialist and Member Services Supervisor.
- Demonstrated proficiency in current Customer Relationship Management (CRM) tool, phone system software, Quality Management Solution, Pharmacy Benefits Management applications (PBM), Interpreter vendor scheduling software; delegate portal solutions and the Member Portal.
- Demonstrated ability to effectively handle the department's key special projects: Member Portal Request Processing, Healthcare PTE Requests, Pharmacy Reimbursements, PCP retroactive requests.
- Demonstrated ability to aid members face-to-face in the field and/or at the main offices (walk-ins). Also, highly skilled at handling issues related to member bills, transportation set-up and care coordination with providers and pharmacy needs.