Member Service Representative

Position Summary

Member Services Representative are the primary point of contact for member inquiries, issues and requests. Service is primarily conducted by telephone, but also includes serving walk-in customers to the Member Services Department.

Position Details

Essential Duties & Responsibilities

• Researches and resolves complex member inquiries and problems including, eligibility verification, benefits, referrals, authorization process and status, complaints, issues with appeals, denials, and claims questions in a timely, respectful, caring and competent manner.
• Answers telephone calls promptly and minimizes delays that may lead to abandoned calls.
• Informs and educates members on managed care, health plan benefits, and operational policies and procedures and services.
• Corrects and updates basic enrollment data daily at the time of the member’s request. (PCP change, address or name change, correction, etc.)
• Provides Chinese/English language interpretation services when necessary, including assisting with arranging of medical appointments, contacting contracted PBM for prescription issues, and DME exchange/return, etc.
• Contacts providers, members and in-house departments to obtain information and resolve issues.
• Performs initial research of problem claims, pulls files, compiles necessary information and forwards to proper department for resolution.
• Documents all member/provider encounters into the Member Service Inquiry Module.
• Assists the Marketing Department with walk-in prospects by promoting CCHP and answering questions regarding the health plan.
• Alerts management of repeat phone calls due to issues that have not been resolved within standards. Recommends suggestions for improving workflow and service.
• Exercises discretion in working with confidential information.
• Member Services Specialist is under mandatory requirement to work in assigned CCHP office locations and take turns to work on rotation scheduled shifts.
• Accepts and performs other duties as assigned.

Qualifications

• Associate degree preferred
• Minimum 1+ years of experience in customer services, call center, or similar
• Prior experience in health plan experience preferred
• Strong PC skills
• Fluency in English required
• Bilingual in Chinese or Spanish Preferred
• Excellent oral communication, customer service and organizational skills
• Ability to work under pressure in a busy call center environment
• Attention to detail and willingness to exercise initiative
• Excellent decision making, research and problem solving skills
• Ability to deal effectively with difficult and emotional people and issues.
• Display a high level of confidence and able to explain information to customers in ways that are clear, concise and objective.

Physical Requirements

• Able to lift up to 30 pounds
• Use proper body mechanics when handling equipment
• Standing, walking and moving 50% of the day.

In our efforts to control the spread of COVID-19 and its variants, CCHP requires that its employees be fully vaccinated as of their start date. If you require a medical or religious accommodation we will engage in the interactive process with you. Proof of vaccination will be required prior to start. If we make you an offer and you are not yet vaccinated, we will accommodate a delay in start date. CCHP may also mandate that its employees receive vaccine boosters, and all accommodation laws will be followed.