Member Services Rep II

Leon Medical Centers • Doral, FL

4d

About The Position

The Member Services Representative connects with prospective and current members, listens to their questions and concerns, and provides clear, concise solutions with an emphasis on first-call resolution. The role handles a high volume of complex calls and may also process correspondence, including mail, faxes, or written letters. It researches accounts, claim history, and benefits to identify issues and resolution steps, and coordinates with the appropriate departments to ensure requests and questions are handled accurately and promptly. The representative identifies complaints (grievances), requests for coverage determinations or appeals, and possible fraud, waste, or abuse for referral to the appropriate department. The role also contributes to CMS call center metrics and company call center goals, follows up with callers as needed, and documents call reasons and dispositions in the call center system.

Requirements

• Understanding of and ability to apply Centers for Medicare and Medicaid (CMS) regulatory requirements and standard operating procedures.
• High school diploma or equivalent.
• At least one year of experience working in a call center in insurance managed care.
• Fluency in English and Spanish.

Nice To Haves

• Experience in a Medicare HMO call center is preferred.

Responsibilities

• Professionally handle a high volume of complex calls and, as needed, process mail, faxes, or written letters.
• Research accounts, claim history, and benefits to identify issues and determine resolution steps.
• Identify the correct department to support timely and accurate resolution when needed.
• Explain to callers any actions required to resolve their inquiries or concerns.
• Identify grievances, requests for coverage determinations or appeals, and possible fraud, waste, or abuse, and forward them to the appropriate department.
• Contribute to meeting or exceeding CMS call center metrics and call center goals.
• Follow up with callers to provide responses or resolution steps as needed.
• Clearly document incoming and outgoing call reasons and dispositions in the call center system.
• Develop and maintain positive customer relations and coordinate with company functions to ensure customer requests and questions are handled appropriately and promptly.

What This Job Offers

• Job Type: Full-time
• Education Level: High school or GED