Customer Engagement - Representative, Member Serv I

Talteam Inc.•Washington, DC

21h

About The Position

The Rep, Member Service I is proficient in routine benefits, claims, and general inquiries. They have a general knowledge of systems, benefits, contracts/products, functions of other departments in the company, standard operating procedures, claims status, enrollment/billing and follow-up to a customer inquiry. This role involves answering member inquiries, resolving service problems, examining claims, calculating financial aspects of claims, executing enrollment transactions, generating billing, administering billing transactions, and identifying clients for managed care interventions. The incumbent uses knowledge of products and contractual provisions to provide client education and interpret contract data. They document client interactions, research and resolve problems related to member data, and analyze client needs. The role also involves supporting enrollment transactions, accessing information from automated systems, and utilizing various automated systems for service administration.

Requirements

High School Diploma or GED
1 year customer service, claims experience, Inbound Call Center Experience
2-5 Years inbound call center experience
Previous customer service and/or claims experience.
Use of automated systems
PC or CRT proficiency
Excellent oral and written communication skills
Time and organizational management
Successful project management

Nice To Haves

Experience performing duties that are detailed in nature, exposure to health care, health insurance, medical information, and direct service experience is preferred.
Experience performing duties that are detailed in nature, exposure to health care, health insurance, medical information, and direct service experience is preferred.
Working knowledge of basic computer functions including Microsoft products, internet research and email communication.
Work experience in a Quality/Production driven environment
Position requires performance in either service or claims for a minimum of 18 months at a meets standard level or above.

Responsibilities

Answers member inquiries by clarifying desired information; researching, locating, and providing information.
Resolves member service problems by clarifying issues; researching and exploring answers and alternative solutions; implementing solutions; escalating unresolved problems.
Examines claims to identify key elements, and processing requirements based on diagnosis, procedures, provider, medical policy, contracts, and policy and procedures.
Calculates deductibles, maximums, and determining resolving, reporting, and following through on overpayments, underpayments, and managed care processes.
Learns and executes enrollment transactions in accordance with contractual and medical underwriting guidelines, generating accurate billing for policies and products purchased by new clients, existing clients, and transfers from other Client Plans.
Learns the details of offering and administering various billing transactions, i.e. direct pay, credit card payment, and debit accounting through the policyholders checking account, and how to effectively interact with or advise clients, group administrators, brokers, or providers on problem resolution.
Identifies clients who are eligible or in need of managed care interventions and collaborates with the clinical professionals in designing and implementing the intervention.
Documents all client interactions according to established procedures.
Examines member records to identify key elements, and processing requirements based on established business rules policies and procedures.
Researches, investigates, and resolves problems related to member data or records and communicates resolution clearly and effectively.
Responds to telephone and written inquiries from internal and external customers regarding contract data.
Provide support for the execution of enrollment transactions in accordance with contractual and medical underwriting guidelines for new clients, existing clients, and transfers to and from other Client and Non Client Plans.
Learns to access information from FEPOC automated systems, and by telephone and written inquiry with various clients.
Responds to client inquiries.