Representative Duties:
- Respond to all member inquiries related to Commercial, Exchange and/or Individual plans via telephone, email, chat, or fax.
- Support other Member Service Representatives by answering questions/clarifications regarding plan rules/policies, benefits, and/or system information.
- Research and resolution of cases that require additional investigation; including, when necessary, cases that involve urgent access to care or involve the Member Relations Unit.
- Provide training and call shadowing of new MSRs.
- Accurately record and refer appeals and grievances according to department protocols and procedures.
- Educate members on the Advantage Referral Program, Western Health Advantage's website, and the self-service tools available to them online.
- Assist members, providers, brokers, and plan partners with claims-related billing questions and issues as needed.
- Work with inter and intra-department staff to help resolve member issues to ensure resolution within prescribed timeframes.
- Meet department standards related to performance and attendance.
- Manage difficult or emotional customer situations, responds promptly to customer needs, solicit customer feedback to improve service, respond to requests for service and assistance, and meet commitments.
- Report any system problems or call drivers needing immediate attention to Member Service Supervisor or Manager immediately.
- Use tact, discretion, and courtesy while interacting with clients, the public, and other encounters in the course of work.
- Perform other duties and special projects as assigned.
All qualified applicants will receive consideration for employment without regard to race, color, national origin, age, ancestry, religion, sex, sexual orientation, gender identity, gender expression, marital status, disability, medical condition, genetic information, pregnancy, or military or veteran status. We consider all qualified applicants, including those with criminal histories, in a manner consistent with state and local laws, including the California Fair Chance Act, City of Los Angeles' Fair Chance Initiative for Hiring Ordinance, Los Angeles County Fair Chance Ordinance, and San Francisco Fair Chance Ordinance.