Member Solutions Representative

Responsibilities:
Essential Functions:
ØConsistent and demonstrated use of excellent interpersonal, reasoning and communication skills.
ØMust demonstrate above average and proficient reading and writing skills.
ØWorks with limited supervision within the context of the day-to-day operations.
ØMust achieve 95% accuracy in consistently meeting service standards and quality measures. This includes providing inbound callers with appropriate information.
ØResolving first level inquiries and complaints to include, but not limited to, pharmacy, appointment and eligibility access in the appropriate timeframes.
ØExtensive follow-up to ensure that member inquiry and first level complaints has been resolved in the appropriate timeframes.
ØDocumentation of transactions in the appropriate databases with minimal achievement of 98% accuracy and timeliness.
ØRouting information to the appropriate resources for resolution or follow-up with 98% accuracy and timeliness.
ØAssignments of primary care providers according to standard. Maintains process to ensure that members receive welcome information and identification cards within 10 days of enrollment.
ØDemonstrates an understanding of the functions of other departments communicates with other departments appropriately and maintains positive working relationships.
ØMaintains corporate and departmental attendance standards
ØDemonstrates job proficiency by meeting and maintaining minimal auditing benchmarks.
ØProvides timely claim research and follow-up as required for member claim issues.
REQUIREMENTS
Knowledge and Skills:
ØExcellent interpersonal and communications skills to effectively communicate with members, providers, or external customers to effectively communicate resolutions through written or telephonic media.
ØAbility to organize, coordinate and prioritize multiple tasks and calls and proven ability to handle escalated and complex complaints using results oriented problem-solving techniques.
ØAbility to accurately and appropriately document all member, provider, and external inquiries/communications in the required format, systems, and databases.
ØAbility to consistently achieve 98% accuracy and timeliness as required to satisfactorily meet compliance initiatives with updated state/federal regulations, plan benefits, and corporate policies and procedures.
ØAbility to sit for extended periods of time to handle high volume in-bound calls.
ØAbility to utilize Microsoft Office Suite software applications with emphasis on Excel and other database software applications.
ØKnowledge and familiarity with CPT, ICD-9 and medical terminology.

Education and Work Experience:
ØHigh school diploma or equivalent GED with experience with a minimum of two year’s of customer service experience preferably within a managed care environment with at least one year of claims experience.