Member & Provider Services Representative

Member & Provider Services Representative

We are seeking a Member & Provider Services Representative to join our team at Independent Living Systems (ILS). ILS, along with its affiliated health plans known as Florida Community Care and Florida Complete Care, is committed to promoting a higher quality of life and maximizing independence for all vulnerable populations.

About the Role:

The Member & Provider Services Representative will serve as an essential point of contact between members, healthcare providers, and administrative teams. The Member & Provider Services Representatives primary objective is to deliver exceptional customer service by efficiently managing both inbound and outbound calls, addressing inquiries, scheduling appointments, and resolving concerns with professionalism and empathy. The Member & Provider Services Representative will contribute to the smooth operation of the contact center by maintaining accurate records and adhering to established protocols and compliance standards. The Member & Provider Services Representative must handle a high volume of calls while maintaining a calm and courteous demeanor, ensuring that each interaction supports positive member experiences and organizational goals. Ultimately, the Member & Provider Services Representatives efforts will help facilitate effective communication and support the delivery of quality health and social care to vulnerable populations.

Minimum Qualifications:

• High School Diploma or GED.
• Proven experience working within healthcare or a related field.
• Ability to manage high volume contact center demands.
• Familiarity with inbound and outbound customer service processes and phone systems.
• Basic clerical experience and technical knowledge including accurate data entry and record keeping.
• Ability to work flexible hours to accommodate contact center shifts.
• Strong interpersonal and communication skills with the ability to engage with diverse populations.

Preferred Qualifications:

• Associate's degree
• Experience specifically in healthcare services or medical contact centers.
• Experience with Microsoft Office Suite
• Knowledge of healthcare terminology and member privacy regulations such as HIPAA.
• Certification in customer service or contact center operations.

Responsibilities:

• Demonstrate commitment to Our Mission and models ILS Experience Standards of Excellence.
• Handle a high-volume of inbound and/or outbound calls, providing accurate information on healthcare services, scheduling, and member and provider inquiries in a professional, courteous, compassionate and empathetic manner.
• Use active listening to identify needs, resolve concerns, educate members and providers, and strive for first call resolution whenever possible.
• Conduct comprehensive reviews of member and provider inquiries, complaints, grievances, and escalated issues by gathering information, obtaining documentation, clarifying circumstances, and facilitating timely resolution.
• Coordinate with internal departments, providers, and other stakeholders to resolve issues, support follow-up needs and escalate concerns when appropriate.
• Manage a high-volume caseload while meeting productivity expectations, service level agreements, regulatory turnaround requirements, and quality standards.
• Accurately document call details, update member records, and utilize contact center systems and clerical tools in accordance with established procedures.
• Ensure compliance with healthcare regulations, service level agreements, organizational policies, and confidentiality standards in all communications.
• Maintain established standards for schedule adherence, attendance, quality, member and provider satisfaction, and performance (including average handle time, after call work time, and outreach targets).
• Demonstrate professionalism through reliability, teamwork, strong work ethic, initiative, organization, and ongoing participation in training and professional development.
• Perform other duties as assigned.