Member Service Representative

Mercy Health System Corporation•Janesville, WI

10d•Onsite

About The Position

Support health insurance members by answering questions, resolving complex issues, and helping patients understand their benefits, coverage, pharmacy needs, and authorization requests. This role serves as a knowledgeable resource for members and team partners while delivering excellent customer service, problem-solving support, and timely follow-up in a fast-paced call center environment.

Requirements

High school education preferred

Responsibilities

Serve as a resource or Subject Matter Expert (SME) for other team members or internal members in the following areas: WI and Illinois Group EPO, HMO, PPO, POS lines of business, WI and Illinois Individual Marketplace, WI Medicaid, WI Medicare Supplemental Insurance, WI and Illinois Pharmacy Riders
Handle escalated calls, resolving more complex member issues in a one-and-done manner
Answer incoming phone calls from members and identify the type of assistance the member needs- Members or someone calling on behalf of members, Providers, Pharmacy
Ask appropriate questions and listen actively to identify specific questions or issues while documenting required information in computer systems
Assist members in navigating Mercyhealth’s websites and encourage and reassure them to become self-sufficient
Assist members in choosing a primary care physician and scheduling their first appointment or when assistance getting an appointment is asked for by the member
Own problem through to resolution on behalf of the member in real-time or through comprehensive and timely follow-up with the member
Research complex issues across multiple databases and work with support resources to resolve member issues and/or partner with others to resolve escalated issues
Provide education and status on previously submitted pre-authorizations or pre-determination requests
Responsible for entering all approved authorizations into the pharmacy benefit management system. Also responsible for entering overrides to ensure members receive their prescriptions promptly.
Assist in taking premium payments from members for our marketplace line of business.
Meet the performance goals established for the position in the areas of first-call resolution, service level, occupancy rate, percentage of calls held, redirect, attendance, NCQA required audits, and any contractual requirements (ETF, Medicaid, etc.)