JOB SUMMARY
The Member Services Representative is responsible for responding to member/provider inquiries within specified parameters. Researches and resolves issues and inquiries in a timely and efficient manner and resolves needs and issues in an empathetic and courteous manner. Applies appropriate triage and escalation protocols. Consistently applies good judgement and reason when resolving issues. Excellent attendance and punctuality are essential for team performance and member satisfaction. Results and performance driven.
RESPONSIBILITIES
- Compliance with call center performance standards. Responsible to answer incoming member/provider calls in accordance with established standards. Consistently meets or exceeds regulatory, contractual and accreditation call center standards including handling the volume of inbound calls, ASA, abandonment rate, call tracking standards, and resolution rate.
- Inquiry Documentation. Documents and tracks 100% inquiries received through the Plan's call center using the Plan's call tracking system. Ensures that all data is entered accurately and timely.
- Customer Inquiries. Receives, responds, researches and resolve all customer inquiries (telephone, walk-in, and written) including but not limited to plan benefits, policies, procedures, eligibility, referrals, authorizations, pharmacy override inquiries and claims.
- Customer Education. Educates members/providers at each encounter on benefits and health plan navigation including alternative customer education resources (i.e. electronic sources). Provides accurate and effective consultation on all aspects of the health plan.
- Member/Provider Satisfaction. Promotes customer satisfaction by ensuring that all customer inquiries are resolved in a timely and efficient manner in accordance with health plan guidelines. Proactively identifies areas for operational and process improvements related to customer satisfaction, identifies solutions, and assists with implementation.
- Member/Provider Data Maintenance. Assists with the maintenance of member/provider data by verifying the accuracy of such data with each member encounter. Processes updates and changes to member data including but not limited to PCP changes and demographic changes.
- Intra Departmental Support. Supports Plan departments through member service call and issues resolution. Provides internal support to external member services consultants and practice sites.
- Research and Resolution. Researches and resolves customer inquiries in a timely and efficient manner. Takes ownership for issues. Follows appropriate triage, resolution and escalation protocols. Confirms that issues are resolved according to customer's satisfaction.
- Aware of the potential for fraud and how to report suspected fraudulent activity.
- Other responsibilities as assigned
EXPERIENCE
- 1 year Customer Service or call center experience.
- Health care experience preferred.
Preferred Experience
- Knowledge of claims processing preferred
- Knowledge of TRICARE Benefit
Education/Licensure/Certification
- Requires High school diploma or equivalent
- Recommended, Associates Degree in healthcare administration, business administration and/or information technology
TECHNICAL SKILLS & Competencies
- Required Microsoft Office skills - Word, Outlook, Powerpoint, Excel, Access
- Experience with standard office equipment - copier, scanner, fax, multiline phone, calculator
- Excellent verbal and written communication skills. Ability to listen well.
- Problem solving capabilities while dealing with conflict, hostility, multiple projects and time constraints.
- Ability to take responsibility and ownership for actions and outcomes despite any obstacles and conflicts.
- Decision making, ability to work with others toward team goals and maintain a positive outlook.
- Dependability - available and dependable for work shift
- Able to file/retrieve documents using an alphabetical filing system
- Fundamental mathematical skills (addition, subtraction, division, calculation of percentages)
Other requirements
- Must have the ability to provide a high-speed internet for a home office
SVCMC IS AN Equal Opportunity Employer - All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability or veteran status.
Job Types: Full-time, Temporary
Pay: $23.87 - $26.64 per hour
Expected hours: 35 per week
Benefits:
- 401(k)
- 401(k) matching
- Dental insurance
- Disability insurance
- Employee assistance program
- Health insurance
- Life insurance
- Paid time off
- Paid training
- Tuition reimbursement
- Vision insurance
- Work from home
Schedule:
- 8 hour shift
- Day shift
- Monday to Friday
Education:
Experience:
- Call center: 1 year (Required)
- Customer service: 1 year (Required)
Ability to Commute:
- New York, NY 10018 (Required)
Ability to Relocate:
- New York, NY 10018: Relocate before starting work (Required)
Work Location: Hybrid remote in New York, NY 10018
