Member Service Representative

Job Overview

JOB DETAILS

REQUIREMENTS

• At least six months recent experience in a call center environment
• Currently or recently employed in customer service, public service, as front-line health care worker, or in a contact center

• Experience and competent in working with a diverse differently abled and elderly population, socioeconomically, ethnically, and culturally
• Experience working independently while in a team environment
• Experience working in a quality-focused environment with an emphasis on behavioral based quality assurance program
• Experience in health care, , health plan, insurance or government is preferred.
• Prior experience working in the health care industry front lines or medical setting preferred
• Prior experience with service authorizations, grievances and appeals, scheduling medical appointments preferred
• Ability to work with multiple computer programs and phone systems at once
• Must be passionate about serving others and able to show empathy to distressed individuals
• Skilled in problem solving by referencing departmental standard operating procedures and workflows
• Resilient and adaptable working in an environment that includes continuous change
• Proven proficiency working in a metrics, benchmarks and goals driven work environment.
• Reliability and punctuality are a must
• Proficient with Microsoft Office Suite and demonstrated ability to work with multiple complex systems simultaneously
• Ability to document information clearly and efficiently using medical terminology
• Excellent interpersonal skills and ability to interact professionally
• Must be kind and respectful when assisting all constituents including challenging callers, with excellence in customer service.
• Superb verbal and written communications skills in English required

RESPONSIBILITIES

• Respond and effectively triage member phone calls to accurately route to appropriate area.
• Work with care management team to address the needs of members, caregivers and other CCA constituents.
• Conduct all follow up activities in a timely and accurate manner ensuring member expectations are met.
• Meticulously document all member and prospective member interactions in a Centralized Electronic System.
• Responsible for the scheduling of member appointments, transportation, translation, and interpretation services.
• Initiates prior authorization intake process.
• Assist in resolving member billing discrepancies.
• Complete comprehensive appeal and grievance intakes.
• Collaborate with the member to accurately document their appeal or grievance concern by ensuring all necessary information to start the process is captured.
• Assist with timely resolution of concerns or complaints conveyed by members and their representative.
• Conduct research to provide accurate and informed resolution to members inquiries.
• Collect supporting data and documentation relevant to members’ care.
• Connect members to their CCA providers through Telemedicine accessibility.
• Must act in compliance with HIPAA, state and federal regulations when assisting CCA members
• Other duties as assigned

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