Representative, Member Serv I

Member Service Representative I

The Rep, Member Service I is proficient in routine benefits, claims, and general inquiries. They have a general knowledge of the following: systems, benefits, contracts/products, functions of other departments in the company, standard operating procedures, claims status, enrollment/billing and follow-up to a customer inquiry.

Essential Functions:

• Answers member inquiries by clarifying desired information; researching, locating, and providing information. Resolves member service problems by clarifying issues; researching and exploring answers and alternative solutions; implementing solutions; escalating unresolved problems.
• Examines claims to identify key elements, and processing requirements based on diagnosis, procedures, provider, medical policy, contracts, and policy and procedures. Calculates deductibles, maximums, and determining resolving, reporting, and following through on overpayments, underpayments, and managed care processes.
• Learns and executes enrollment transactions in accordance with contractual and medical underwriting guidelines, generating accurate billing for policies and products purchased by new clients, existing clients, and transfers from other Client Plans. Learns the details of offering and administering various billing transactions, i.e. direct pay, credit card payment, and debit accounting through the policyholders checking account, and how to effectively interact with or advise clients, group administrators, brokers, or providers on problem resolution.
• Identifies clients who are eligible or in need of managed care interventions and collaborates with the clinical professionals in designing and implementing the intervention.

Qualifications To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education Level: High School Diploma or GED

Experience: 1 year customer service, claims experience, Inbound Call Center Experience Preferred Qualifications Experience performing duties that are detailed in nature, exposure to health care, health insurance, medical information, and direct service experience is preferred.

Knowledge, Skills and Abilities (KSAs) Self-starter with strong organizational skills and planning skills. Proficient Ability to maintain effective interpersonal relationships, Proficient Ability to recognize, analyze, and solve a variety of problems. Proficient Excellent communication skills both written and verbal. Proficient Maintains quality customer services by following customer service practices; responding to customer inquiries.