Member and Provider Services Specialist

Brief Description Harbor Health Member & Provider Services Specialist Texas Markets | Member & Provider Services | Full-Time Position Overview Harbor Health is seeking a compassionate, highly skilled, and solution-oriented Member & Provider Services Specialist to join our innovative, integrated healthcare organization. As a key ambassador of the Harbor Health experience, you will serve as a trusted resource for members, providers, and business partners by delivering exceptional service across both our health plan and medical group. You will support a broad spectrum of member and provider inquiries throughout the healthcare journey — including educating members on benefits and coverage, resolving claims and billing questions, supporting enrollment and eligibility, assisting with referrals and prior authorizations, and managing complaints, grievances, and appeals in accordance with regulatory requirements. This role is central to delivering Harbor Health's commitment to a unified, frictionless, member-centered experience that aligns with our mission of transforming healthcare through our payvider model. Position Duties & Responsibilities Member Services Serve as the primary point of contact for members through phone, email, chat, and other communication channels Educate members regarding health plan benefits, eligibility, covered services, exclusions, deductibles, copays, coinsurance, and out-of-pocket responsibilities Assist members with provider selection, appointment scheduling, referrals, and navigation throughout the healthcare system Guide members through enrollment, eligibility updates, PCP changes, and Marketplace or Large Group insurance questions Assist members with portal registration and digital self-service tools Promote first-call resolution while delivering a personalized, empathetic member experience Provider Services Serve as a primary resource for participating and non-participating providers Support provider inquiries regarding member eligibility, benefits, claim status, payment, referrals, prior authorizations, and network participation Educate providers on Provider Relations and Network Management processes to resolve provider concerns efficiently Eligibility & Benefits Verify member eligibility and benefits using Athena, payer portals, and internal systems Confirm benefit coverage, network participation, plan limitations (HMO, PPO, POS, Marketplace, etc.), and applicable member financial responsibility Educate members regarding referral requirements and available in-network resources to improve access and reduce out-of-pocket costs Resolve eligibility discrepancies by working directly with health plans or guiding members through corrective actions Claims & Billing Support Research and resolve claims inquiries for members and providers Explain claim adjudication, payment determinations, denials, coordination of benefits, and reimbursement processes Assist with billing questions, patient balances, payment options, and payment plan information Escalate complex financial or reimbursement issues to Claims or Billing teams while maintaining ownership of the member experience Prior Authorization & Referrals Educate members and providers regarding prior authorization requirements, referral processes, and documentation needs Explain authorization status, next steps, and expected turnaround times Coordinate with Utilization Management and Clinical Operations to facilitate timely resolution Appeals, Grievances & Complaints Intake and document member and provider complaints, grievances, and appeals accurately and completely Ensure all required documentation is collected to support investigations and regulatory review Maintain compliance with CMS, TDI, NCQA, HIPAA, and Harbor Health policies Escalate potential compliance, quality of care, patient safety, or regulatory issues appropriately Network Access & Care Navigation Identify access-to-care concerns and potential network adequacy issues Assist members in locating participating providers and obtaining timely appointments Escalate network access barriers in accordance with regulatory access standards Support members through complex care coordination and navigation needs Documentation & Communication Manage high-volume inbound and outbound phone calls, emails, and written correspondence Accurately document all member and provider interactions in applicable systems Maintain detailed case notes while ensuring confidentiality of Protected Health Information (PHI) Follow approved communication standards while personalizing interactions to meet individual member needs Operational Excellence Meet established quality, productivity, attendance, and service level expectations Demonstrate flexibility in a rapidly evolving healthcare environment Participate in ongoing training, coaching, and professional development Support continuous improvement initiatives designed to enhance the member and provider experience Required

DESIRED PROFESSIONAL SKILLS & EXPERIENCE

High School Diploma or equivalent; Associate's or Bachelor's degree preferred 2+ years of experience in a healthcare contact center, member services, or provider services role Working knowledge of health insurance operations including eligibility, benefits, claims, prior authorizations, referrals, and appeals/grievances processes Familiarity with CMS, TDI, NCQA, and HIPAA compliance requirements as they relate to member and provider services Proficiency with EMR and payer portal systems; experience with Athena a plus Exceptional customer service, communication, and active listening skills Strong analytical and problem-solving skills with the ability to navigate multiple systems simultaneously Ability to manage high call and case volume while maintaining accuracy and compassion Demonstrated ability to work collaboratively across cross-functional teams Strong attention to detail and documentation discipline Preferred Experience in a payvider, integrated delivery system, or health plan environment Familiarity with Medicare Advantage, Medicaid, ACA Marketplace, or employer group insurance products Experience handling appeals, grievances, or regulatory complaint processes Knowledge of medical terminology, CPT/ICD-10 coding, or claims adjudication Bilingual in English/Spanish What We Offer Competitive salary and incentives Generous PTO 10 paid holidays Medical, Dental, and Vision Insurance 401(k) Investment Plan Company Equity Professional development and growth opportunities At Harbor Health, we're transforming healthcare in Texas through collaboration and innovation. We're seeking passionate individuals to help us create a member-centered experience that connects comprehensive care with a modern payment model. If you're ready to make a meaningful impact in a dynamic environment where your contributions are valued, please bring your talents to our team! #J-18808-Ljbffr Harbor Health