Member Services Representative

Primary Responsibilities:

The Member Services Representative serves as a point of contact for health care plan participants (employees and dependents), company human resources representatives and providers regarding plan eligibility, plan services, benefits coverage, provider reimbursement, claims questions and processing. Receives and processes inbound correspondence and documentation including mail, email, faxes and delivery and, in turn, sorts, delivers and files according to established processes. Receives various medical records and other documentation and ensures that they are uploaded into electronic documentation system with correct naming convention, dispersing records to proper person/department. May also provide administrative support for Provider Contracting Departments and works closely with Care Coordination, Care Navigation, and Claims Teams.

REPRESENTATIVE DUTIES AND RESPONSIBILITIES: The items listed below detail some of the assigned duties and responsibilities for this position. This is not meant to be an all-inclusive list, and management reserves the right to change these duties at any time.

• Receive, respond to and/or refer inbound employee, provider and physician documentation through fax, mail and email or other delivery methods.
• Receive, log, scan and route vital pieces of claim documentation including Refund Checks, Medical Records or other documents.
• Attach DCN numbers to claims and correspondence in various systems such as QC and document imaging system.
• Track their receipt, electronically upload into correct intake coordinator folder or electronic record; maintain medical record archives.
• Verifies returned mail and makes necessary updates within applicable systems.
• Performs daily Mail Merge letter report. Send out letters to correct providers and members via fax and US Mail as required.
• Retrieve & deliver departmental mail and outgoing correspondence.
• Work collaboratively with all HealthPlan Teams to ensure that best practices are identified and shared.
• Work with other departments to research and resolve their questions and concerns within scope of responsibility.
• Identifies and escalates repetitive questions and/or problems so that corrective action can be pursued and expedited.
• Perform other projects and duties as needed.

Knowledge and Skills Required

• Outstanding customer services skills.
• Excellent listening skills with the ability to interpret and understand underlying issues and unasked questions.
• Familiarity with medical claims processing, denials and appeals process in a health care plan environment.
• Knowledge of health care customer service, Health Plan and regulatory requirements and provider dispute and/or member appeal process.
• Knowledge of CPT/HCPC, ICD9/10 coding, procedures and guidelines helpful.
• Excellent vocabulary, grammar, spelling, punctuation, and composition skills proven through the development of written communication.
• Ability to maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA) and fraud and abuse prevention detection policies and procedures
• Ability to establish and maintain positive and effective working relationships with coworkers, plan members and providers.
• Strong computer skills and familiarity with Microsoft Office required and cloud-based file storage systems preferred.

Education and experience:

• At least 1 years of experience in a healthcare or medical insurance customer service role with direct payment and provider contact preferred.