Member Relations Representative- Medicaid

3 months ago

Philadelphia, United States Jefferson Health Plans Full time

Why Choose Jefferson Health Plans?


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

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. Founded over 35 years ago, Health Partners Plans continually develops new ways to encourage better health outcomes and has received national recognition for our innovations in managed care.

This position will work on site at our Community Wellness Center in Philadelphia, PA. 

Perks of JHP and why you will love it here:

• Competitive Compensation Packages including 401(k) Savings Plan with Company Match and Profit Sharing 
• Flextime and Work-at-Home Options
• Benefits & Wellness Program including generous Time Off 
• Impact on the communities we service 


We are seeking a talented and enthusiastic Member Relations Representative to join our team

The Medicare 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. Responds to complex external and internal inquiries in a professional, informative, and courteous manner This role requires mastering and demonstrating skills and concepts within the Medicare business (enrollment, appeals and grievances, Complaint Tracking Module, claims, billing, marketing, etc.). 

As the Member Relations Representative, your daily duties may include: 

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. Other duties as assigned.

Qualifications 

High School Diploma or GED required.  Excellent communication and interpersonal skills required.  3-5 years customer service experience preferred.  Managed care experience preferred. 

Skills, We Value: 

Excellent written and verbal communications skills.  Bilingual a plus  Ability to work independent of direct supervision, but also must be able to work within a Team.  Proficiency in Departmental Information Systems including DPW, Member Health Information System and Pharmacy Systems. 

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