Member Services Representative I / Job Req 872720192

Member Services Representative

Hybrid : Applicants must be a California resident as of their first day of employment.

Principal Responsibilities :

Member Services Representatives (MSR) are the first point of contact for our members primary contact with the Alliance for both routine and complex member issues with the goal of delivering excellent customer service to our customers. The position is responsible for answering a high volume of inbound and outbound calls in a timely manner. Respond to all communications coming into Member Services in the form of email, fax, letters, chat and phone calls. Timely responses to all member communication are essential. Must effectively prioritize and flex the workload as new communication and tasks are submitted. Identify the callers needs, clarify information, research issues, and provide solutions and / or alternatives whenever possible. Accurately and consistently document all conversations in the electronic database. This position is a liaison between the plan, the provider network, and other community agencies. The MSR positions are flexibly staffed classification and work is expected to be performed minimally at the MRS II level. However, the initial selection will be made at the entry level MSR I. Our more advanced level position of the series is the MSR III who will be required to perform a variety of complex matters. Member Services Representatives are under the direction of a Member Services Supervisor, Manager and Director, and service our members through our call center as well as assisting other departments with responses to member issues by initiating communication between departments to ensure action, cooperation, and compliance of managed care operations.

Member Services Representative I :

This position which requires the ability to work as a team player within the Alliance and with external contacts, make sound judgments based on analysis of information, be an effective communicator, active listener and balance advocacy for the member with the policy provisions such as plan policies, EOC, regulatory guidelines, and DMHC / DHCS rules and regulations. The MSR provides courteous, professional, and accurate responses to incoming inquiries regarding network, plan benefits, eligibility, authorizations, plan services and guidelines, as well make decisions with the goal of ensuring member satisfaction and retention. The MSR performs a variety of complex functions and is also responsible for maintaining accurate and complete inquiry / grievance records in the electronic database. Maintains compliance with DMHC regulatory requirements and DHCS contractual obligations. MSR I staff who demonstrate proficiency in meeting, maintaining and exceeding principal performance objectives and metrics may be eligible to be promoted to a Member Services II or III role. Member Services Representative I staff may be eligible for promotion to Member Services Representative II or III positions once they have worked as a MSR I for a minimum of 12 months to be proficient with program and system knowledge in addition to meeting performance matrix requirements.

Principle duties and responsibilities :

Serve as the primary contact for members, providers and others for questions related to claims, benefits, authorizations, pharmacy, member eligibility and other questions related to Alameda Alliance and provide accurate, satisfactory answers to their inquiries or concerns. Respond to and resolve member service inquiries and issues by identifying the topic and type of assistance the caller needs such as benefits, eligibility, claims, behavioral health, and care coordination Answer incoming calls, emails, chats, and other requests for assistance in a timely manner in accordance with departmental performance targets and provide excellent customer service while doing so. May include assisting members in person Recognize and understand the difference between calls that require quick resolutions and calls which will require follow-up and handle each appropriately. De-escalate situations involving dissatisfied customers, offering patient assistance and support. Accurately document all contacts per department standards / guidelines in the Customer Relationship Management (CRM) system Accurately and consistently document (electronic database) and resolve Exempt Grievances (any expression of dissatisfaction that are not coverage disputes, disputed health care services involving medical necessity, or experimental or investigational treatment and that are resolved by the next business day following receipt). Interface with Grievance and Appeals, Claims, Enrollment, IT, Network Management, Pharmacy, Authorizations, and other internal departments to provide Service Excellence to our members. Help guide and educate members about the fundamentals and benefits of managed health care topics, to include managing their health and well-being by selecting the best benefit plan service options, maximizing the value of their health plan benefits, and choosing a quality care provider. Intercede with care providers (doctors offices) on behalf of the member, assisting with appointment scheduling; connect members with internal Case Management Department for assistance as needed. Assist members in navigating alamedaalliance.org, the Member Portal, and other health care partner online resources and websites to encourage / reassure them to use self-service tools that are available. Manage any issues through to resolution on behalf of the member, either on a single call or through comprehensive and timely follow-up. Research complex issues across multiple databases and work with support resources to resolve member issues and / or partner with others to resolve escalated issues. Provide education and status on previously submitted pre-authorizations or pre-determination requests for both medical and pharmaceutical benefits Meet the performance goals established for the position in the areas of compliance, efficiency, call quality, member satisfaction, first call resolution, punctuality, and attendance. Always maintain a professional level of service to members.