Member Service Representative

2 weeks ago

Boston, United States Commonwealth Care Alliance Full time

**Why This Role is Important to Us**:
The Member Services Department provides a single point of contact for questions, problem solving, and access to care, for members and all those involved in CCA members' care. The Member Service Representative (MSR) is responsible to provide a best-in-class service experience to all constituents, including enrolled and prospective members, Commonwealth Care Alliance internal workforce, and employees of state and federal agencies. The MSR serves as a facilitator for member inquiries and assists with accessing care. This position focuses on educating members on health plan benefits, products, and services, and will triage calls to the appropriate destination. The MSR will also report to and receive daily instruction from contact center leadership. After training, the MSR will be expected to have a solid understanding of operational, telecom, and IT related systems specific to contact centers in the health care industry. This position is remote and the contact center is staffed 7 days per week from 8AM-8PM ET including most holidays. Typical shifts are 8:00 am-4:30 pm, 9:30 am-6:00 pm and 11:30 am-8:00 pm ET. You are aligned to a schedule for a minimum of 6 months following training.

We are looking for tenacious, personable, and compassionate individuals who are able to solve problems while delivering outstanding customer service to our members. Individuals who are reliable, empathetic, and thrive in a challenging work environment, you could be a great addition to our team. Ability to service our members in Spanish as well as English is a plus.

**What You'll Be Doing**:
Key Responsibilities:

- Be a resource for CCAs members by providing accurate and timely responses to their benefit and health plan questions.
- 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.
- Provide members with any requested documents including provider listings in their areas.
- 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 indicators
- Other duties as assigned

**What We're Looking For**:
Required Education:

- Associate's degree or equivalent experience.

Desired Education:

- A bachelor's degree in any general or health-oriented field is preferred. Technical accreditation in the health care field (i.e., Medical Assistant | Billing and Coding) is a plus.

Required Experience:

- 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

Desired Experience:

- 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

Required Knowledge, Skills & Abilities:

- 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
- Document information c

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