Member Services Representative II

Cascade Comprehensive Care Inc•Klamath Falls, OR

About The Position

This position is responsible for interacting with members and providers, analyzing inquiries and providing clear and accurate information in a timely manner. This position is also responsible for maintaining policies and procedures and providing new staff training, and tracking progress by performing the following duties. Provides member benefit information in a clear and concise manner. Assists members and provider partners with authorizations, assignments, eligibility, claim status, and researches inquiries that require additional information not readily available in the internal or external member data systems. Develops and maintains Member Services department policies and procedures, workflows, and desktop processes. Provides support and guidance to the Member Services Representative I staff and serves as a backup to the Member Services Representative III, when necessary. Analyzes member and provider inquiries and determines steps for resolution and is first level of contact for call escalations. Ensures accuracy of member information and assists members with redetermination processes for continuation of coverage. Assists members with benefit coverage questions and provides guidance and support for member needs. Completes provider check run processes as assigned. Develops and maintains task tracking workspaces and notifications. Assists in developing and maintaining Member Services call scripting documentation. Conducts regular note review of the member services team in the data systems and assists in maintaining department standards. Conducts appropriate research and follow-up for prompt resolution of claims, social needs requests, and prior authorization inquiries. Relays information to appropriate departments and personnel using established communication procedures and provides timely follow-up and status updates to members as calls are processed and resolved. Documents calls in a clear and consistent manner and in the appropriate data systems. Initiates welcome touch point calls to new members. Provides new staff and ongoing training to include but not limited to, policies and procedures, job tasks and call shadowing, benefit coverage, prioritized list changes and Oregon Administrative Rules (OARs). Monitors and analyzes member satisfaction survey results. Enters data in various programs requiring proficient and accurate typing skills. Balances multiple tasks utilizing excellent organizational skills and prioritizes necessary steps to accomplish tasks timely and accurately. Mains confidentiality and complies with HIPAA rules and regulations. Mains punctual, regular and predictable attendance. Works collaboratively in a team environment with a spirit of cooperation. Displays excellent communication skills including presentation, persuasion, and negotiation skills required in working with members and coworkers and including the ability to communicate effectively and remain calm and courteous under pressure. Respectfully takes direction from manager.

Requirements

High school diploma or general education degree (GED); and four to six years related experience and/or training; or equivalent combination of education and experience.
Has advanced basic computer job skills including logging on to systems, ability to communicate by email, ability to compose documents, enter database information, create presentations, download forms, and preserve/backup important data.

Responsibilities

Provides member benefit information in a clear and concise manner.
Assists members and provider partners with authorizations, assignments, eligibility, claim status, and researches inquiries that require additional information not readily available in the internal or external member data systems.
Develops and maintains Member Services department policies and procedures, workflows, and desktop processes.
Provides support and guidance to the Member Services Representative I staff and serves as a backup to the Member Services Representative III, when necessary.
Analyzes member and provider inquiries and determines steps for resolution and is first level of contact for call escalations.
Ensures accuracy of member information and assists members with redetermination processes for continuation of coverage.
Assists members with benefit coverage questions and provides guidance and support for member needs.
Completes provider check run processes as assigned.
Develops and maintains task tracking workspaces and notifications.
Assists in developing and maintaining Member Services call scripting documentation.
Conducts regular note review of the member services team in the data systems and assists in maintaining department standards.
Conducts appropriate research and follow-up for prompt resolution of claims, social needs requests, and prior authorization inquiries.
Relays information to appropriate departments and personnel using established communication procedures and provides timely follow-up and status updates to members as calls are processed and resolved.
Documents calls in a clear and consistent manner and in the appropriate data systems.
Initiates welcome touch point calls to new members.
Provides new staff and ongoing training to include but not limited to, policies and procedures, job tasks and call shadowing, benefit coverage, prioritized list changes and Oregon Administrative Rules (OARs).
Monitors and analyzes member satisfaction survey results.
Enters data in various programs requiring proficient and accurate typing skills.
Balances multiple tasks utilizing excellent organizational skills and prioritizes necessary steps to accomplish tasks timely and accurately.
Maintains confidentiality and complies with HIPAA rules and regulations.
Maintains punctual, regular and predictable attendance.
Works collaboratively in a team environment with a spirit of cooperation.
Displays excellent communication skills including presentation, persuasion, and negotiation skills required in working with members and coworkers and including the ability to communicate effectively and remain calm and courteous under pressure.
Respectfully takes direction from manager.