Member Service Specialist

Job Description

Job Description

POSITION SUMMARY:

Effectively manage member needs and benefits by providing answers to patient questions, process claim adjudication, and manage plan enrollments. Maintain provider relations by creating authorization numbers, complete provider credentialing, maintain contracts, and location updates.

DUTIES AND RESPONSIBILITIES:

• Answer Member Services queue line in a timely manner. Assist patients with eligibility, benefits, locating stores, and resolving problems

• Maintain all providers on CAQH and Gemini for credentialing. Update provider information in software, on directory, and on website. Follow up with providers regarding missing information, record due, and completion of credentialing

• Review and research upload errors from retail location. EDI claim through TriZetto. Complete rejection letters and maintain rejection log. Partner with providers to resolve claim errors

• Maintain contracts with groups and brokers

• Process end of month payout. Review all claims for accuracy, generate appropriate reports, submit affiliate and referral claims to Accounts Payable department for payment. Generate group rate reports and send to Accounts Receivable department for invoicing.

• Respond to and trouble shoot with other departments and stores regarding claim and authorization errors

• Process remakes, benefit reinstatements, and commission payments

• Maintain store programs and support (agent on record)

• Develop and maintain standard and shelf pricing

• Develop and maintain sales collaterals

• Program development

• Maintain strategic partnerships

• Develop and maintain ancillary programs (safety, school grants, etc.)

• Assist with health fairs offsite as needed

MINIMUM KNOWLEDGE, EXPERIENCE & SKILLS REQUIREMENTS:

• High School Diploma or equivalent

• Vocational or Technical training – Field of Study: CPC, CBCS, RHIT or similar

• Associate degree or bachelor’s degree in business administration, management, communication or related field

• Combination of education and/or equivalent work experience in a related field

• Knowledge of billing, coding, credentialing, and HIPPA a plus

• 1-3 years of progressively responsible experience in member services field

• 0-1 years of supervisory experience

• Focused, customer-centric mindset

• Excellent communication and interpersonal skills, with the ability to build relationships

• Exceptional organizational and time management skills, with the capacity to prioritize and manage multiple tasks simultaneously

• Strong problem solving and critical thinking skills

• Flexibility and adaptability to work in a fast-paced, dynamic environment

• Proficiency with MS Office Suite of programs

ESSENTIAL FUNCTIONS & WORK REQUIREMENTS:

• Ability to effectively communicate at all levels within the organization through written and two-way verbal communication

• Able to sit or stand for extended periods of time

• Able to operate various office equipment (e.g., personal computer, telephone, fax machine, copier, etc.)

• Able to read and write at a high school graduate level

• Able to lift 10 to 20 pounds

• Able to work normal and/or extended (evenings, nights, and weekends) office hours to meet established deadlines

• Able to travel independently to support Company objectives and personal development

These statements are intended to describe the general nature and level of work performed by teammates assigned to this job classification. They are not intended to be an exhaustive list of all responsibilities, duties and skills required.