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 Member Services Representative I
This is an entry level position which requires the ability to work as a team player within the Alliance and with external contacts, make sound judgements based on analysis of factual information, be an effective communicator, and balance advocacy for the member with the policies of the health plan. The MSR provides courteous, professional, and accurate responses to incoming inquiries regarding network, plan benefits, eligibility, authorizations, plan guidelines, and policies and procedures, as well as claims and pharmacy issues. The MSR performs a variety of complex functions and is also responsible for administrative and technical duties requiring a thorough knowledge of the managed care operations, the Alliance provider network, coordination of benefits between Medi-Cal and Medicare (and other health insurance/ OHI), various software applications, and managed care regulations from DHCS, Title 18, Title 22, DMHC, Medicare, and Knox Keene Act. MSR I staff who demonstrate proficiency in meeting principal performance objectives and metrics may be eligible to be promoted to a Member Services II role. Member Services Representative I staff may be eligible for promotion to Member Services Representative II positions once they have worked as a MSR I for a minimum of 12 months in order to be proficient with program and system knowledge in addtion to meeting performance matrix requirements.
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.
ESSENTIAL FUNCTIONS OF THE JOB
· Contacts: Receive, manage and document telephone calls, emails, and other sources of contacts from members, potential members, and providers, and explain health plan benefits and plan rules. Describe the types of services the Alliance offers to the Member within the managed care system. Provide clarification about issues regarding patient and physician rights and how the plan operates.
· Conflict resolution: Resolve member problems/conflicts by convening with other departmental staff as needed.
· Member communications: Create and/or mail appropriate member materials and communications as needed.
· Meetings: Participate in both departmental and non-departmental meetings.
· Computer: Perform ongoing data entry which assists in the maintenance of the Member Services department database to ensure data integrity.
· Comply with the organization’s Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.
· Constant and close visual work at desk or computer.
· Constant sitting and working at desk.
· Constant data entry using keyboard and/or mouse.
· Frequent use of telephone headset.
· Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
· Frequent lifting of folders, files, binders and other objects weighing between 0 and 30 lbs.
· Frequent walking and standing.
EDUCATION OR TRAINING EQUIVALENT TO:
· Two years of college or equivalent office work, customer service work in call center environment.
MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:
· Minimum two years of direct customer service experience.
· Call center experience and managed care experience a plus
· Experience determining eligibility for financial assistance, insurance benefits, unemployment and/or other social services programs.
· Demonstrated knowledge expert of AAH Member Services policies and procedures
· Demonstrated track record of schedule adherence (punctuality and attendance), including consistent use of the company’s time tracking solution to track working hours.
· Consistent record of meeting or exceeding monthly call center production metrics (ACD and/or Outbound; 5% missed calls, 29% unavailable, <=6minutes average talk time, <2 minutes average hold time, and average wrap<45 seconds. time.)
· Consistent track record of documenting Service Requests accurately and clearly, and monitoring open Service Requests to ensure responses and closure.
· Consistent record of high quality of work as demonstrated through call and documentation auditing, appropriate Call Disposition coding, as well as an overall acceptable monthly Member Satisfaction Survey result as assessed by Member Services Quality Specialist and Member Services Supervisor.
· Demonstrated proficiency in current Customer Relationship Management (CRM) tool, phone system software Quality Management Solution, Pharmacy Benefits Management applications (PBM), Interpreter vendor scheduling software; delegate portal solutions and the Alliance’s Member Portal.
· Demonstrated ability to effectively handle the department’s key special projects: Member Portal Request Processing, Kaiser PTE Requests, Pharmacy Reimbursements, PCP retroactive requests.
· Demonstrated ability to provide assistance to members face-to-face in the field and/or at the Alliance offices (walk-ins). Also highly skilled at handling issues related to member bills, transportation set-up and care coordination with providers and pharmacy needs.
$18.57 - $27.86/hour