Member Services Representative

The Member Services Representative serves as a point of contact for health care plan participants (employees and dependents), company human resources representatives and providers regarding plan eligibility, plan services, benefits coverage, provider reimbursement, claims questions and processing. Receives and processes inbound correspondence and documentation including mail, email, faxes and delivery and, in turn, sorts, delivers and files according to established processes. Receives various medical records and other documentation and ensures that they are uploaded into electronic documentation system with correct naming convention, dispersing records to proper person/department. May also provide administrative support for Provider Contracting Departments and works closely with Care Coordination, Care Navigation, and Claims Teams.

• →Outstanding customer services skills.
• →Excellent listening skills with the ability to interpret and understand underlying issues and unasked questions.
• →Familiarity with medical claims processing, denials and appeals process in a health care plan environment.
• →Knowledge of health care customer service, Health Plan and regulatory requirements and provider dispute and/or member appeal process.
• →Knowledge of CPT/HCPC, ICD9/10 coding, procedures and guidelines helpful.
• →Excellent vocabulary, grammar, spelling, punctuation, and composition skills proven through the development of written communication.
• →Ability to maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA) and fraud and abuse prevention detection policies and procedures
• →Ability to establish and maintain positive and effective working relationships with coworkers, plan members and providers.
• →Strong computer skills and familiarity with Microsoft Office required and cloud-based file storage systems preferred.

• At least 1 years of experience in a healthcare or medical insurance customer service role with direct payment and provider contact preferred.