Member Experience Specialist

GuideWell•Irving, TX

3d•Hybrid

About The Position

WebTPA, a GuideWell Company, is a healthcare third-party benefit administrator with over 30+ years of experience building unique benefit solutions and managing customized health plans. The Member Experience Specialist will work in conjunction with the Account Executive to seek to improve the member experience for their dedicated clients by engaging with members and HR Benefits leaders to identify and uncover needs and providing solutions to escalated issues. They should proactively identify potential issues ensuring the organization is consistently providing exceptional member service and overall client service. This function is hybrid and resides within the Account Management team including working cross functional as needed with claims, customer service, analytics, and clinical. The Member Experience Specialist goal is to drive high quality, cost effective results for plan members and sponsors, with the ultimate goal of being a good steward of the plan's health care spend. The MES role will participate in WebTPA's development program for new team members to the business and to WebTPA. MES roles will move throughout the operational structure of WebTPA, leading and trained in 1) customer service, 2) claims processing, 3) eligibility/EDI, 4) analytics,5) reporting, and 6) client relationship management etc.

Requirements

1+ years related work experience.
Related Bachelor’s degree or additional related equivalent work experience from an accredited university; preferably in Business, communications or experience working the medical insurance field.
Strong proficiency with Microsoft Office.
Strong verbal and written communication skills; ability to tailor communications based on audience and business objectives.
Comfortable working and communicating at very high levels across operational areas and working in cross-functional teams.
Maintain confidentiality and observe HIPAA requirements.
Strong customer service skills.
Ability to work independently/autonomously and proactively as well as collaboratively as a member of a team.
Must thrive in a team environment; team success will be heavily emphasized.
Must be a self-starter with the ability to identify problems/issues and offer workable solutions.
Ability to prioritize or seek information on how to best prioritize projects.
Project confidence, high energy, enthusiasm, and high regard for client advocacy and service.

Nice To Haves

One to three years’ experience in the health insurance administration industry a plus.

Responsibilities

Responsible for designing member solutions for clients, engaging directly with internal operational departments and assisting client’s Human Resource’s team members.
Design and execute proactive member issue escalation resolution strategies.
Eligibility responsibility, managing and troubleshooting Client EDI files and ensure eligibility implementation is finalized by established dates.
Initiate claims investigation, negotiate settlements, interpret medical records, respond to Department of Insurance complaints, and authorize payment to claimants and providers.
Serve as the immediate escalation resource for customer service reps and claims examiners.
Responsible for researching claims where applicable.
Outbound proactive outreach to members, as determined by the escalation, Account Executive and at the direction of client’s HR Benefits leadership.
Resolve member issue escalation routed through member calls or HR Benefits leadership.
Triage and escalate member issues to the necessary department when appropriate.
Engage with members to ensure previous issues have been resolved in a timely manner.
Support members and providers to the best experience in addressing OON facility services, provider billing challenges.
Maintain good rapport with physicians, healthcare facilities, clients, providers and internal and external stakeholders.
Review and process insurance to verify medical necessities and coverage under policy guidelines.
Utilize systems to track complaints and resolutions.
Responsible for basic reporting and analytics demonstrating service level performance for clients.