Member Services Specialist

South Country Health Alliance has an immediate need for an Member Services Specialist at our Medford Office

The Member Services Specialist acts as the primary point of contact in our Call Center. The Member Services Specialist provides accurate information and assistance to members involving enrollment, transportation, benefit questions, coverage limits, payments, claims, and those matters that involve provider networks. This may be over the phone or in person.

Hours can include on call, holidays, and late shift hours with differential as needed.

South Country offers a full range of comprehensive benefits such as medical, dental, vision, PERA pension, and competitive pay.

This position is a grade 3 and salary ranges from a minimum of $18.87 to $21.02/ hour, based on experience.

Member Services Specialist

Department: Operations

Reports To: Manager of Member Services

Pay Grade: Grade 3: Non-Exempt

Supervises: None

Approved By: Cheri Lewer; Mel Lique

JOB PURPOSE or JOB SUMMARY:

As the primary point of contact in our Call Center, the Member Services Specialist provides accurate information and assistance to members involving enrollment, transportation, benefit questions, coverage limits, payments, claims, and those matters that involve provider networks. This may be over the phone or in person.

QUALIFICATIONS:

Required: High school diploma or equivalent. At least one year of practical experience in customer service or call center required.

Preferred: Bilingual; Post high school education in business; Healthcare or insurance experience; Knowledge of Medicaid and Medicare rules.

Skill Sets: Computer savvy and proficient in the use of Microsoft Office Suite and Chrome in order to navigate and retrieve information from a variety of software and internet applications, including numerous third party administrator (TPA) systems; Self-directed, highly organized and very detail oriented in completing multiple assigned tasks simultaneously; Conversational with a variety of personality styles; High level of patience to work with a diverse caller group; Good written communication skills to document calls in a clear and concise manner; Excellent verbal communication skills and enjoy working with the public via telephone for extended periods of time; Adaptable to a continually changing environment and able to maintain a high degree of confidentiality.

ESSENTIAL DUTIES and RESPONSIBILITIES:

The duties and responsibilities listed below reflect the general details necessary to describe the essential functions of the position and shall not be construed as the only duties that may be assigned for the position. % of Total Time

• Provides assistance to members with questions, concerns, and complaints they may have regarding their enrollment, benefits, and/or services provided by South Country in a professional and efficient manner that allows members to receive exceptional service and accurate information. 40%

• Participate in the day-to-day RideConnect program to effectively schedule member transportation requests. This may include intaking requests, verification of appointments, identification of the most cost-effective provider, outreach to providers to check availability, book rides, confirm rides with members, coordinate ride modifications, ride cancellations, and other tasks necessary to coordinate transportation. 10%

• Utilize and navigate multiple computer systems, including a cloud-based phone system, to provide service to our members. Procedures and workflows are followed accurately and completely. 30%

• All interactions are documented (calls, emails, and face to face conversations) in CRM software to ensure that any audit, follow-up communication, grievance or appeal can be handled in an accurate, appropriate, and timely manner. 10%

• Assist Community Care Connectors (CCC) and other county staff with benefit questions, location of network providers, pharmacy issues, member materials, etc. in order that members are provided with the best continuum of care possible. 3%

• Be aware of, or be able to obtain, Federal, State, and County laws and rules that regulate the provision of health care services to South Country members, including those that apply to enrollee Grievances and Appeals, in order that South Country and its employees are in compliance with such laws and rules and that members suffer no loss of coverage. 3%

• Determine when an issue needs to be escalated to supervisor or other management personnel. 3%

• Perform other duties as assigned within the scope, responsibility, and requirements of the job. 1%

QUALIFICATION REQUIREMENT

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 accommodation may be made to enable individuals with disabilities to perform the essential functions.

LANGUAGE SKILLS

Must be able to read and write in English. Knowledge of Spanish and/or Somali languages a plus. Ability to access interpretation services, if needed.

MATHMATICAL SKILLS

Basic mathematical skills required.

ACCURACY

It is critical for the Member Services Specialist to communicate accurate information to enrollees regarding their healthcare benefits. The impact of errors or negligence in communicating incorrect information/benefits could be significant. In these instances, members could miss or be late for their medical appointments, and South Country could incur costs of paying claims for inaccurate services not in the member's benefit set. Quality checks may identify these errors, but this would be during a retro review.

REASONING ABILITY

Must be able to draw conclusions from past practice, essential information, rules and regulations, and common sense. Requires the use of judgment to research and make decisions in communicating benefits. Problem solving may be of a more challenging degree.

PHYSICAL DEMANDS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to talk or listen. The employee frequently is required to sit for lengthy periods of time. The employee is occasionally required to stand, walk; use hands to finger, handle, or feel objects, tools, or controls; and reach with hands and arms.

WORK ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee should encounter no unusual or hazardous conditions. The noise level in the work environment does vary depending on call volume and number of member services staff on duty.

TRAVEL REQUIREMENTS

This position has limited exposure to out-of-town travel but may be required to occasionally travel.

CONTACTS/RELATIONSHIPS

The Member Services Specialist obtains specific cooperation from personnel regarding work received from another or work delivered to another. This position has constant contact with enrollees, both via telephone and face-to-face, and works closely with the community care connectors, specific internal staff, as well as several TPAs and has occasional contact with providers.

The Member Services Specialist will communicate with members in a professional, courteous manner that will build trust, enabling the enrollee to have full confidence that they are receiving the correct information regarding their benefits. Based upon their experience assisting enrollees in solving benefit issues or concerns, this position will help to develop policies and procedures that can be used as guidelines when similar situations arise in the future.

FINANCIAL IMPACT

Errors in communicating benefits to members could negatively impact South Country at a moderate to significant level depending on the individual situation. If a Member Services Specialist indicates to a member that a service is covered, but it really is not, South Country could incur the costs of paying those claims.