Job Title : Member Services Representative

Location : Remote (Must be in Oklahoma)

Duration : 3 months contract

Shift Timing : Between 8am - 5pm M-F

Job Description :

Front line customer service inbound call center representative (telephonic-no sales) assisting members, prospective members and providers with questions regarding benefits, pharmacy services, provider listings, etc.

in a high volume, fast paced, call center environment.

• Responsible for increasing member and provider satisfaction, retention, and growth by efficiently delivering competitive services to members and providers through a fully integrated organization staffed by knowledgeable, customer-focused professionals supported by exemplary technologies and processes.
• Customer Service Representative is the face of Client's and impacts members' service experience by manner of how customer service inquiries and problems via telephone, internet or written correspondence are handled.
• Customer inquiries are of basic and at times complex nature.
• Engages, consults, and educates members based upon the member’s unique needs, preferences and understanding of Insurance plans, tools and resources to help guide the members along a clear path to care.

Responsibilities :

• Answers questions and resolves issues based on phone calls / letters from members, providers, and plan sponsors.
• Triages resulting rework to appropriate staff.
• Documents and tracks contacts with members, providers, and plan sponsors.
• The CSR guides the member through their members plan of benefits, Client's policy and procedures.
• as well as having knowledge of resources to comply with any regulatory guidelines.
• Creates an emotional connection with our members by understanding and engaging the member to the fullest to champion for our members' best health.
• Taking accountability to fully understand the member’s needs by building a trusting and caring relationship with the member.
• Anticipates customer needs. Provides the customer with related information to answer the unasked questions, e.g. additional plan details, benefit plan details, member self-service tools, etc.
• Uses customer service threshold framework to make financial decisions to resolve member issues.
• Explains member's rights and responsibilities in accordance with contract.
• Processes claim referrals, new claim handoffs, nurse reviews, complaints (member / provider), grievance and appeals (member / provider) via target system.
• Educates providers on our self-service options; Assists providers with credentialing and re-credentialing issues.
• Responds to requests received from Client’s Law Document Center regarding litigation, Lawsuits.
• Handles extensive file review requests.
• Determines medical necessity, applicable coverage provisions and verifies member plan eligibility relating to incoming correspondence and internal referrals.
• Handles incoming requests for appeals and pre-authorizations not handled by Clinical Claim Management.
• Performs review of member claim history to ensure accurate tracking of benefit maximums and / or coinsurance / deductible.

Performs financial data maintenance as necessary.

Uses applicable system tools and resources to produce quality letters and spreadsheets in response to inquiries received.

Experience :

Customer Service experiences in a transaction-based environment such as a call center or

retail location preferred, demonstrating ability to be empathetic and compassionate.

Experience in a production environment.

Skills :

Customer service, Medicare, Claims

Education :

• High School or GED equivalent.

Last updated : 2024-04-28