Member Services Representative

2 weeks ago

Miami, United States Solis Health Plans Full time
Job DescriptionJob Description

Solis Health Plans is a new kind of Medicare Advantage Company. We provide solutions that are more transparent, connected and effective for both our members and providers. Solis was born out of a desire to provide a more personal experience throughout all levels of the healthcare journey. Our team consists of expert individuals that take pride in delivering quality service. We believe in a culture that collaborates and supports one another, and where success is interlinked and each employee is valued.


**Position is FULLY ONSITE Mon-Friday, Bilingual in Spanish is required**

Location: 9250 NW 36th St, Miami, FL 33178

Solis offers competitive benefits including:

  • Paid Time Off
  • Paid Holidays
  • Paid Long Term Disability & Life Insurance policy
  • 401k Matching Program
  • Health, Vision & Dental Insurance
  • Critical Illness, Hospital and Accident Insurance
  • Legal & Transit benefits
  • Employee Appreciation Events
  • Positive & Supportive Work Environment

Position Summary

Solis Health Plans is looking for a Member Services Representative primarily responsible for providing quality, professional service to all customers when calls are received through the Member Services Department via telephone, written or in-person in accordance with Plan guidelines.

Essential Duties and Responsibilities

  • Handles telephone, written and in-person inquiries in a courteous, professional, thorough, and timely manner to assure member satisfaction.
  • Assists callers on inquiries regarding coverage decisions, grievances, appeals, benefit interpretation, eligibility verification, medical group/PCP, explanation of how the plan works and how to utilize services, assists with information regarding referrals or authorizations, member complaints, identification card requests.
  • Must Report to the Doral HQ.
  • Responsible for maintaining customer service levels (abandonment rate, speed of answer and service level) within established parameters.
  • Is knowledgeable on plans benefit, CMS and Plans policies and procedure.
  • Applies high level of subject matter knowledge to solve a variety of common business issues.
  • Provides quality services effectively to increase the overall level of customer service and satisfaction as measured by CMS.
  • Identifies the differences between a Grievance, Appeal or Coverage Decision and process the request through the appropriate channels.
  • Identify, handle, document and/or route Utilization Management inquiries appropriately
  • Identify and document Coverage Determinations.
  • Documents all inquiries and complaints.
  • Interacts with other departments about member issues or concerns.
  • Approaches work in a meticulous and thorough manner, pays attention to detail and follows company scripts.
  • Manages time effectively and prioritizes tasks to meet deadlines.
  • Assists customers, family members and others with concern and empathy; respect their confidentiality and privacy and communicate with them in a courteous and respectful manner.
  • Complies with company policies and procedures and maintains confidentiality of customer medical records in accordance with state and federal laws.
  • Ensures compliance with all HIPAA, OSHA, and other federal, state and local regulations.
  • During AEP, October 1 through March 31st they are required to be a part of the weekend rotation.
  • Participates in meetings, trainings and in-service education, as required.
  • Highly regulated environment.
  • Time frames to handle issues are in accordance with CMS time frames.
  • Interacts with members, family members, staff, visitors, government agencies, etc., under a variety of conditions and circumstances.

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. Sits, stands, bends, lift, and moves intermittently during working hours. 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 as needed.

Qualification and Education

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  • Minimum of High School diploma or equivalent.
  • Minimum of 1year healthcare experience is required, with a preference for plan experience.
  • Working knowledge of the Privacy and Security Health Insurance Portability and Accountability Act (HIPAA) regulations.
  • Excellent communication skills, attention to detail, ability to set priorities appropriately and meet strict deadlines and the ability to manage multiple tasks simultaneously is required.
  • Excellent listening, interpersonal, verbal and written communication skills with individuals at all levels of the organization.
  • Excellent computer knowledge is required, including proficient knowledge of Microsoft Office
  • Familiarity with healthcare laws, regulations and standards.
  • Ability to compute basic arithmetic and work with numbers.
  • Must be patient in dealing with an elderly population and sympathetic to hearing or vision deficiencies.
  • Ability to work effectively independently, work with very little supervision and in a team environment.
  • Ability to read, analyze, and interpret technical procedures or governmental regulations.
  • Ability to effectively present information and respond to questions from groups of managers, clients, customers and the general public.
  • Ability to define problems, collect data, establish facts, and draw valid conclusions.
  • Strong decision-making, analytical skills.
  • Must be self-motivated, organized and have excellent prioritization skills.
  • Must be able to work well under stressful conditions.
  • Must be able to work in a fast paced environment.
  • Fluency in English and Spanish.


What set us apart

Join Solis Health Plans as a Member Services Representative and become a catalyst for positive change in the lives of our members. At Solis, you will be part of a locally rooted organization deeply committed to understanding and serving our communities. If you are eager to embark on a purpose-driven career that promises growth and the chance to make a significant impact, we encourage you to explore the opportunities available at Solis Health Plans. Join us and be the difference

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