Member Services Specialists 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.
ESSENTIAL DUTIES AND 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.
- Associate degree preferred
- Minimum 1+ years of experience in customer services, call center, or similar
- Prior experience in health care and knowledge of managed care of Medi-Cal preferred
- Strong PC skills
- fluency in English and Cantonese
- 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.
- Able to lift up to 30 pounds
- Use proper body mechanics when handling equipment
- Standing, walking and moving 50% of the day.