Member Support Specialist I

2 weeks ago

Alameda, California, United States Alamedaalliance Full time
Overview


As a Member Services Representative I, you will serve as the initial point of contact for our members, addressing both routine and intricate inquiries with the aim of providing exceptional customer support.

Key Responsibilities


Your primary duties will include managing a significant volume of inbound and outbound communications promptly. You will respond to various forms of member inquiries, including emails, faxes, letters, chats, and phone calls, ensuring timely and effective communication.

It is essential to prioritize and adapt your workload as new tasks arise. You will identify the needs of callers, clarify information, investigate issues, and offer solutions or alternatives whenever feasible. All interactions must be accurately documented in our electronic database.

This role acts as a crucial link between the plan, the provider network, and other community organizations.

Position Requirements


The MSR positions are designed to be flexibly staffed, with work expected to be performed at the MSR II level at a minimum. However, initial hiring will occur at the entry-level MSR I. The advanced level position in this series is the MSR III, which entails handling a variety of complex matters.

Under the guidance of a Member Services Supervisor, Manager, and Director, you will assist our members through our call center and collaborate with other departments to address member issues by facilitating communication between teams to ensure action, cooperation, and compliance with managed care operations.

Essential Functions


As the primary contact for members, providers, and other stakeholders, you will address inquiries related to claims, benefits, authorizations, pharmacy, and member eligibility, providing accurate and satisfactory responses.

You will resolve member service inquiries by identifying the topic and type of assistance required, such as benefits, eligibility, claims, behavioral health, and care coordination.

Timely responses to incoming calls, emails, chats, and other requests are critical, and you will provide excellent customer service while adhering to departmental performance targets.

Additionally, you will assist members in person when necessary, recognizing the distinction between calls that require immediate resolution and those that necessitate follow-up.

Effective de-escalation of situations involving dissatisfied customers will be part of your responsibilities, along with accurate documentation of all contacts per departmental standards in the Customer Relationship Management (CRM) system.

Collaboration and Education


You will interface with various internal departments, including Grievance and Appeals, Claims, Enrollment, IT, Network Management, Pharmacy, and Authorizations, to provide exceptional service to our members.

Educating members about managed health care topics, guiding them in selecting the best benefit plan service options, and maximizing the value of their health plan benefits will be essential.

You will assist members in navigating the Member Portal and other online resources, encouraging the use of available self-service tools.

Managing issues through to resolution, whether on a single call or through comprehensive follow-up, will be part of your role.

Researching complex issues across multiple databases and collaborating with support resources to resolve member issues will also be required.

Performance Goals


Meeting established performance goals in compliance, efficiency, call quality, member satisfaction, first call resolution, punctuality, and attendance is crucial.

Maintaining a professional level of service and confidentiality of information at all times is expected.

Supporting the organization's approach to Service Excellence by adhering to established standards for all work-related functions is essential.

Qualifications


A high school diploma or GED is required, with a preference for a bachelor's degree or equivalent experience. Bilingual proficiency in designated languages is necessary, and candidates will undergo a bilingual proficiency exam.

A minimum of one year of direct customer service experience, preferably in a call center or managed care environment, is required.

Demonstrated knowledge of member services policies and procedures, along with a consistent record of meeting performance metrics, is essential.

Proficiency in current CRM tools and relevant software applications is expected.

Strong problem-solving skills, excellent communication abilities, and the capacity to maintain composure in stressful situations are vital for success in this role.

Flexibility to adjust to changing situations and the ability to work collaboratively within a team are also important.

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