Member Guide - Wall, New Jersey

Amynta Group•NJ - Remote, NJ

9d•Onsite

About The Position

The Member Guide serves as an advocate and single point of contact for members seeking help with healthcare and employee benefits. This in-office role supports members as they navigate medical, dental, vision, voluntary, and employer-paid benefit programs, offering guidance on coverage, claims, providers, care options, and medications. The Member Guide takes ownership of member inquiries from initial contact through resolution, coordinating with carriers, providers, pharmacies, and other partners as needed. The role assesses members’ needs and coverage, connects them with appropriate programs and care solutions, explains benefits in plain language, and helps them access high-quality, cost-effective care. The Member Guide also identifies recurring issues and shares recommendations to improve member support and team practices.

Requirements

At least 2 years of experience in health insurance, benefits administration, a provider office, a pharmacy, or healthcare customer service.
Working knowledge of health plan terms, including deductibles, copays, networks, EOBs, and prior authorizations.
Empathy and strong written and verbal communication skills, including the ability to assist stressed or frustrated members.
Proactive approach, including anticipating member needs and persistently following issues through to resolution.
Sound independent judgment and confidence in deciding appropriate actions for members.
Strong organization and ability to manage multiple open cases.
Comfort using computers and learning new systems, including Microsoft Office or Google Workspace.
Understanding of HIPAA and appropriate handling of protected health information.
Bachelor’s degree.

Responsibilities

Assess each member’s needs, benefits, coverage, and circumstances to determine an appropriate course of action.
Learn employer benefit point solutions and connect members with programs that fit their needs and coverage.
Explain medical, pharmacy, dental, vision, voluntary, and employer-paid benefits, including applicable coverage, limitations, costs, and next steps.
Identify and verify providers and care options that match members’ needs, location, preferences, and coverage; compare quality, cost, and convenience and recommend appropriate options.
Help members access high-quality, lower-cost care options, including Centers of Excellence, preferred providers, and lower-cost sites of care.
Coordinate appointments and plan follow-up steps, referrals, and additional support as needed.
Work with pharmacies, prescribers, and pharmacy benefit managers to address medication denials, formulary exceptions, supply problems, and refill issues.
Coordinate prior authorization requests, identify missing information or delays, and work with providers and health plans to move requests forward.
Manage cases from initial contact through resolution by phone, email, and secure member portal; document actions and decisions and follow up within service-level agreements.
Refer billing and claims issues to Billing Guides.
Set case priorities, determine next steps, adjust approaches, and seek additional expertise or escalation when needed.
Identify patterns in member problems and recommend workflow, procedure, and member-education improvements to the Manager of Member Services and Chief Client Officer.
Share knowledge from complex cases with colleagues and contribute ideas to improve consistent and effective team support.