Member Service Representative
1 month ago
Essential Functions:
- 25% Answers member inquiries by clarifying desired information; researching, locating, and providing information.
- Resolves member service problems by clarifying issues; researching and exploring answers and alternative solutions; implementing solutions; escalating unresolved problems.
- 25% Examines claims to identify key elements, and processing requirements based on diagnosis, procedures, provider, medical policy, contracts, and policy and procedures.
- Calculates deductibles, maximums, and determining resolving, reporting, and following through on overpayments, underpayments, and managed care processes.
- 25% Learns and executes enrollment transactions in accordance with contractual and medical underwriting guidelines, generating accurate billing for policies and products purchased by new clients, existing clients, and transfers from other Client Plans.
- Learns the details of offering and administering various billing transactions, i.e. direct pay, credit card payment, and debit accounting through the policyholders checking account, and how to effectively interact with or advise clients, group administrators, brokers, or providers on problem resolution.
- 25% Identifies clients who are eligible or in need of managed care interventions and collaborates with the clinical professionals in designing and implementing the intervention.
- High School Diploma or GED.
- 1 year customer service, claims experience, Inbound Call Center Experience.
- Experience performing duties that are detailed in nature, exposure to health care, health insurance, medical information, and direct service experience is preferred.
- 3-5 Years Experience.
- Possess a passion for Customer Service.
- Innovative thinking and drive for results.
- Display exceptional oral and written communication skills.
- Capability to navigate concurrently between multiple software systems with relative ease.
- bility to interface with a culturally diverse population.
- Working knowledge of basic computer functions including Microsoft products, internet research and email communication.
- Work experience in a Quality/Production driven environment.
- Position requires performance in either service or claims for a minimum of 18 months at a meets standard level or above.
- Must have previous customer service and/or claims experience.
- dditional required experience includes use of automated systems, PC or CRT proficiency, excellent oral and written communication skills, time and organizational management, and successful project management.
- Experience performing duties that are detailed in nature, exposure to health care, health insurance, medical information, and direct service experience is preferred.
- Exposure to project management and supervision is helpful.
- Bachelor Degree is preferred.
- MS Office Suite, Visio, Adobe Acrobat, FEP Direct, OnBase, Any Doc, Client.
- Self-starter with strong organizational skills and planning skills.
- bility to maintain effective interpersonal relationships.
- bility to recognize, analyze, and solve a variety of problems.
- Excellent communication skills both written and verbal.
- Maintains quality customer services by following customer service practices; responding to customer inquiries.
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