Member Service Representative II (Hybrid)

CareFirst•Washington, DC

2d•Hybrid

About The Position

The Rep, Member Service II is responsible for complex benefits, claims, and general inquiries. They have broader knowledge of the following: 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.

Requirements

3 years customer service, claims, inbound call center experience.
Self-starter with strong organizational skills and planning skills.
Ability to maintain effective interpersonal relationships.
Ability to recognize, analyze, and solve a variety of problems.
Excellent communication skills both written and verbal.
Resolves customer concerns by obtaining information from customer service representative; calling customer back with new information.
Must be able to meet established deadlines and handle multiple customer service demands from internal and external customers, within set expectations for service excellence.
Must be able to effectively communicate and provide positive customer service to every internal and external customer, including customers who may be demanding or otherwise challenging.
Must be eligible to work in the U.S. without Sponsorship

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.

Responsibilities

Answers complex member inquiries by clarifying desired information; researching, locating, and providing information.
Resolves complex 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 BCBS 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.
Assist with training of new hires.