Member Services Processing Specialist

Job Description

REQUIREMENTS

• High School Diploma or equivalent.
• 1–3 years of experience in processing, administrative support, data entry, customer service, or a related operational role.
• Strong written and verbal communication skills.
• Ability to follow detailed procedures, meet deadlines, and adapt to changing priorities.
• Strong attention to detail with the ability to analyze documentation to determine if it meets program requirements.
• Location: Remote
  Clearance: Must be able to obtain and maintain a Public Trust
  Travel: 0-10%

Preferred

• Background supporting federal health programs or healthcare operations.
• Experience working with intelligent document processing tools, member service portals, or customer support platforms such as ServiceNow or CXone.

RESPONSIBILITES

• Process enrollment applications, documentation, certifications, transfers, appeals, and designated representative appointments and updates in accordance with program policies, SOPs, and federal requirements.
• Review member-submitted materials for completeness, accuracy, and eligibility, ensuring all required data is properly captured and validated.
• Analyze documentation submitted with the application and assess if the submission meets the requirements of program enrollment.
• Perform data entry and record updates within member services tools—including digital mail center systems, entry portal, and intelligent document processing platforms—ensuring timely routing and processing of member documentation.
• Maintain accurate and high-quality case notes, documentation, and processing records for program review, compliance, and audit readiness.
• Communicate professionally with members, providers, and internal stakeholders regarding documentation requirements, missing information, or status updates.
• Escalate complex or ambiguous cases to the Member Services Processing Supervisor for review and guidance.
• Adhere to HIPAA and program privacy requirements when handling PII/PHI.
• Support quality assurance activities by identifying errors, trends, or potential improvements and providing feedback to leadership.
• Participate in cross‑training and process updates to ensure efficient support across multiple workflows, including enrollment, record updates, appeals routing, and member correspondence.
• Contribute to continuous improvement efforts by providing insight into workflow challenges, system issues, or enhancement opportunities.

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