Member Services Rep II

Turn every conversation into an opportunity to make a difference. As a Member Services Representative, you’ll connect with prospective and current members, listen to their questions and concerns, and provide clear, concise solutions with a focus on first-call resolution. Bring your communication skills and passion for helping others to a role where every interaction matters.

ESSENTIAL DUTIES AND RESPONSIBILITIES

Professionally handles a high volume of complex calls and may also process correspondence (mail, faxes or written letters). Researches accounts, claim history or benefits to identify issues and resolution steps. Identifies the correct department to assist with timely and accurate resolution as needed. Able to explain to the caller any action that is required in order to resolve the inquiry or concern.

Identifies complaints (grievances), requests for coverage determinations or appeals, and possible fraud, waste or abuse to forward to the correct department for research and resolution. Contributes to meeting or exceeding CMS call center metrics and Call center goals. Follows up with caller to provide response or resolution steps as needed.

Clearly documents incoming and outgoing call reasons and dispositions in the call center system. Develops and maintains positive customer relations and coordinates with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner.

QUALIFICATIONS

Understanding and ability to apply Centers for Medicare and Medicaid (CMS) regulatory requirements and standard operating procedures.

EDUCATION

High School Diploma or equivalent. WORK EXPERIENCE Minimum one (1) year of experience working in a call center in insurance managed care, preferably a Medicare HMO. LANGUAGE SKILLS Bilingual English/Spanish fluency.