Medicare Member Services Representative

WVU Medicine•Home Work - Monongalia County WV (Local), WV

About The Position

The Medicare Member Services Representative joins the Peak Health team at WVU Medicine and supports the Peak Advantage Medicare plan. The representative handles inbound calls from Medicare Advantage members and providers, answering questions ranging from general information to complex issues. The role works with management and peers to research and resolve member concerns and questions. It also makes outbound calls to members and providers to resolve issues or gather additional information. The scheduled work week is 40 hours, with an eight-hour shift scheduled Monday through Friday between 7:30 a.m. and 8:00 p.m.

Requirements

High school diploma or equivalent.
One year of experience handling Medicare claims or related experience.
Working knowledge of administrative and clerical procedures and systems, including word processing and managing files and records.
Ability to take direction and navigate multiple systems simultaneously.
Excellent written and oral communication, customer service, interpersonal skills, and telephone etiquette.
Ability to solve problems using predefined methods and guidelines to improve efficiency and customer satisfaction.
Familiarity with medical insurance services processes.
Exceptional attention to detail, organization, and ability to perform multiple tasks simultaneously.
Ability to work remotely, including reliability, self-motivation, focus, and time-management skills.
Ability to sit and answer phone calls for extended periods and lift 10–25 pounds; travel requirement is 0%–25%.

Nice To Haves

Associate degree or higher in a related healthcare field.
Three or more years of experience in a fast-paced call environment with processing and/or customer service experience.
Two years of experience with Medicare benefits.
Two years of experience with CMS guidelines.
Experience supporting Dual Eligible Special Needs Plans (D-SNP), including working knowledge of Medicaid benefits, care coordination, eligibility requirements, and integration of Medicare and Medicaid services for complex member needs.
Experience assisting members with D-SNP eligibility determinations, enrollment, benefit inquiries, and navigation of Medicare and Medicaid resources.

Responsibilities

Verify member information while addressing general questions.
Respond to and resolve issues and inquiries to support an efficient, seamless member experience.
Maintain member communications and conduct outreach as required.
Address inquiries related to Medicare claims processing.
Meet production and quality standards and maintain work queues according to department standards.
Communicate effectively with internal and external staff.
Escalate issues to the next level of supervision when appropriate.
Ensure the accuracy of information gathered and shared on a member’s behalf.
Attend required training and demonstrate proficiency and the ability to learn.
Maintain accurate documents, including timekeeping records.
Perform other duties as deemed appropriate by the Management Team.
Take inbound calls from members and providers and make outbound calls to resolve issues or gather information.