Member Relations Representative- Medicaid

3 weeks ago

Philadelphia, Pennsylvania, United States Jefferson Health Plans Full time
About Jefferson Health Plans

We are an award-winning, not-for-profit health maintenance organization dedicated to creating a community where everyone belongs, acknowledges, and celebrates diversity and has opportunities to grow to their fullest potential.

Our Mission

We offer Medicaid, Medicare, and Children's Health Insurance Program (CHIP) plans that include special benefits to improve the health and wellness of our members. We're also committed to boosting the health of our community through outreach, education, and events.

Job Summary

We are seeking a talented and enthusiastic Member Relations Representative to join our team. The Member Relations Representative promotes a positive image of Jefferson Health Plans via telephone, utilizing each contact as an opportunity to educate callers about the plan, support resolution of Care Gaps through administrative support for the Care Coordination Program and retain members by providing high levels of service.

Responsibilities
  • Educate callers about Jefferson Health plan with the intent of retaining members and addressing gaps in care and supporting care coordination through appointment scheduling, transportation assistance, and referrals to care coordinators as necessary.
  • Answer eligibility, benefits and provider inquiries, assuring that members receive service, use the plan correctly and gain a high level of satisfaction with the plan.
  • Collaborate with internal departments to facilitate resolutions to member's issues and concerns.
  • Respond to member and member-related calls in a courteous, professional & efficient manner providing timely follow-up to requests for information and service.
  • Report on trends and issues which impact the membership.
  • Conduct targeted telephonic outreach to members using a prepared script depending on Manager's direction.
  • Enroll members in the Care Coordination Program as indicated by criteria.
  • Open or build new cases in the care management system and route to the appropriate staff following the direction of the Team Leader or Manager.
  • Research members' demographics and build cases in healthcare management system by: Calling hospitals, PCP offices, and/or home care agencies to locate a member's most recent phone number.
  • Schedule and coordinate transportation needs.
  • Identify and assist with care gaps.
  • Document all care coordination activities in a member's case, per appropriate CCMS screens.
  • Utilize the language line as indicated by the needs of the member.
  • Refer members to the appropriate Nurse Advice lines and appropriate programs.
  • Maintain accurate data entry into designated software systems.
  • Promote excellent communication between Quality Management (QM), Utilization Management (UM), Care Coordination, Healthcare Economics and Special Needs Unit (SNU).
  • Maintain call records, logs and other documentation in accordance with departmental requirements.
  • Operate all applications and telephone systems effectively and efficiently, following established protocols for security, transfer and information exchange.
  • Participate in appropriate staff meetings and training sessions, reporting on trends and issues which impact members and Health Partners as a whole.
  • Attend monthly meetings as scheduled.
  • Perform other clerical and support tasks as assigned.
Requirements
  • High School Diploma or GED required.
  • Excellent communication and interpersonal skills required.
  • 3-5 years customer service experience preferred.
  • Managed care experience preferred.

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