Member Services Representatives (MSR) are the first point of contact for our members’ primary interaction with the Alliance for both routine and complex member issues. The MSR provides benefits coordination and customer service for members, and their authorized representative. This position is a liaison between the plan, the provider network, and other community agencies. The MSR positions are flexibly –staffed classification and work is expected to be performed minimally at the MRS II level. However, the initial selection will be made at the entry level MSR I. Our more advanced level position in the series is the MSR III, who will be required to perform a variety of complex matters.
Member Services Representatives are under the direction of a Member Services Supervisor and Director. MSRs service our members through our call center as well assisting other departments with responses to member issues by initiating communication between departments to ensure action, cooperation, and compliance of managed care operations.
The MSR III position represents recognition of Member Services Representative II staff who have demonstrated higher proficiency in key aspects of the job requirements for a MSR series maintaining call quality scores of 95% or higher.
Principle duties and responsibilities
· Serve as the primary contact for members, providers and others for questions related to claims, benefits, member eligibility and other questions related to Alameda Alliance.
· Respond to and resolve member service inquiries and issues by identifying the topic and type of assistance the caller needs such as benefits, eligibility, claims, behavioral health, and care coordination.
· Answer incoming calls, emails, and other requests for assistance in a timely manner in accordance to departmental performance targets and provide excellent customer service while doing so. May include assisting members in person.
· Recognize and understand the difference between calls that require quick resolutions and calls which will require follow-up and handle each appropriately.
· Accurately document all calls/contacts as required by department standards via the Customer Relationship Management (CRM) system.
· Interface with Claims, Enrollment, IT, Network Management, Pharmacy, Authorizations and other internal departments to provide Service Excellence to our members.
· Help guide and educate members about the fundamentals and benefits of managed health care topics, to include managing their health and well-being by selecting the best benefit plan service options, maximizing the value of their health plan benefits and choosing a quality care provider.
· Intercede with care providers (doctor’s offices) on behalf of the member, assisting with appointment scheduling; connect members with internal specialists for assistance as needed.
· Assist members in navigating alamedaalliance.org, the Member Portal, and other health care partner online resources and websites to encourage/reassure them to use self-service tools that are available.
· Manage any issues through to resolution on behalf of the member; either on a single call or through comprehensive and timely follow-up.
· Research complex issues across multiple databases and work with support resources to resolve member issues and/or partner with others to resolve escalated issues.
· Provide education and status on previously submitted pre-authorizations or pre-determination requests for both medical and pharmaceutical benefits.
· Meet the performance goals established for the position in the areas of: efficiency, call quality, member satisfaction, first call resolution, punctuality and attendance.
· Ability to work in either Alameda or other company locations within Alameda County.
· Maintain a professional level of service to members at all times.
· Maintain confidentiality of information at all times.
· Consistently support the Alliance’s approach to Service Excellence by adhering to established department and company standards for all work-related functions.
· Interact positively with all Alliance Departments.
· Attend and actively participate in department staff and other meetings as needed. Communicate learned experiences with all members of the Member Service department.
· Accurately document and monitor for resolution of all Claims, Enrollment, Network Management, Pharmacy, Authorization matters and other related issues.
· Conduct telephonic member outreach regarding Medi-Cal benefits and services.
· Establish and maintain internal and external contacts.
· Perform other duties as assigned.
EDUCATION OR TRAINING EQUIVALENT TO:
· Bachelor’s Degree in health related field or five years of Medi-Cal Managed Care experience. OR sustaining 95 points or higher per month for at least 2 years following completion of the one year as MSR II will be considered eligibility to promote to Member Services Representative III.
MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:
· Minimum three years’ experience in managed health care call center, Medi-Cal managed care or eligibility preferred.
SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):
· Excellent interpersonal skills with the ability to interact with diverse individuals and flexibility to customize approach to meet all types of member communication styles and personalities.
· Strong verbal and written communication skills.
· Demonstrated ability to quickly build rapport and respond to members in a compassionate manner by identifying and exceeding member expectations (responding in respectful, timely manner, consistently meeting commitments).
· Demonstrated ability to listen skillfully, collect relevant information, determine immediate requests and identify the current and future needs of the member.
· Must be self-motivated and able to work with minimal supervision.
· Must be team-oriented and focused on achieving organizational goals.
· Proficient problem-solving approach to quickly assess current state and formulate recommendations.
· Proficient in translating healthcare-related jargon and complex processes into simple, step-by-step instructions which members can understand and act upon.
· Proficient conflict management skills to include ability to resolve issues during stressful situations and demonstrating personal resilience.
· Ability to work regularly scheduled shifts within the Alliance’s hours of operation including the training period, with scheduled lunches and breaks, flexibility to adjust daily schedules; and to work over-time and/or weekends as needed.
· Medical terminology knowledge preferred.
· Ability to work within a broad systems perspective.
· Experience in use of various computer systems software as well as Microsoft Windows, and Microsoft Suite, especially Outlook, Word and Excel.