Member Services Representative (Dearborn, MI)

Elevance Health • Dearborn, MI

4d • Hybrid

About The Position

Member Services Representative (Dearborn, MI) Exemption Status: Non-Exempt Reports to: Manager, Member Services Job Code: Salary Grade: Union – Grade 4 Virtual: This role enables associates to work virtually full-time, with the exception of required in-person training sessions, providing maximum flexibility and autonomy. This approach promotes productivity, supports work-life integration, and ensures essential face-to-face onboarding and skill development. Alternate locations may be considered if candidates reside within a commuting distance from an office. Please note that per our policy on hybrid/virtual work, candidates not within a reasonable commuting distance from the posting location(s) will not be considered for employment, unless an accommodation is granted as required by law. Shift hours: Thursday/Friday 1:30am-12pm and Saturday/Sunday 8:00am-6:30pm EST. The Member Services Representative will answer subscriber and provider questions about benefits, eligibility, claims and certification. Ensure customer satisfaction and promote a positive corporate public image. Screen incoming subscriber and provider calls/inquiries and take data to initiate cases. Quote accurate benefit and policy information regarding inpatient and alternative levels of care. Handle complicated inquires and educate providers/subscribers in the certification process and reconcile inconsistencies and procedural difficulties when necessary Perform all data entry for case initiation and update and enter data into system for non-participating providers. Special projects and all other duties as assigned. How you will make an impact: Perform responsibilities and tasks in ways that promote good will, build positive relationships, preserve human dignity, and contribute positively to the corporation service orientation. Service calls in a professional and courteous manner. Perform review of service requests for complete information. Answer telephone calls identifying those needing case management services, those needing referral to routine outpatient services, and those needing authorization and/or verification. Answer questions from providers, members, insurance carriers and/or Beacon regional offices. Certify benefits per account for specific guidelines. Provide a list of in-network providers to callers. Explain the benefits and benefit maximums that have been reached. Verifies benefits against contract requirements prior to case initiation. Refers complicated cases to Case Managers. Collect and transfer non-clinical data. Acquire structured clinical data. Perform activities that do not require evaluation or interpretation of clinical data. Attend all staff meetings, team conferences and in-service as directed. Comply with all credentialing and other PSO requirements. Assist to train new unit personally and to set up new clinical case management units as directed. Assist in special projects as directed by the Department Manager/Supervisor. Assist clinical area managers to prepare for re-authorization of services by gathering necessary information and retrieving relevant subscriber files. Assist to maintain subscribers’ files. Assist Clinical Case Managers to complete claims investigations and facilities claims payment by verifying authorizations, verifying member eligibility, and researching provider information. Record complaints, grievances, and appeals. Collects demographic data from providers/subscribers for case initiation. Completes data entry for authorizations. Perform data entry for case initiation and updates. Research and investigate claims inquiries. Document all inquiries. Apply Beacon policies and procedures consistently. Maintain confidentiality of Clients, Business Records and Reports. Maintain ethical and professional standards. Maintain individual productivity and performance standards. Meet Departmental expectations, accuracy, productivity, and performance standards. Support Beacon in achieving Mission Statement. Adhere to the components of the Compliance Program. Ensure that job tasks are performed in a legal and ethical manner. Actively assess work area for non-compliance issues and notify supervisor or call Ethics Hotline. Adhere to compliance training requirements and understand that training is required condition of employment. Complete tasks accurately and within required timeframes.

Requirements

• High school diploma or a GED equivalent.
• A minimum of one year of customer service experience or experience in the behavioral health care field.
• Strong customer service orientation, and excellent written and verbal communication skills especially telephone service skills required.
• All applicants will be required to demonstrate their customer service skills by participating in a test phone call simulation.

Nice To Haves

• Behavioral Health experience preferred
• Call center experience preferred

Responsibilities

• Answer subscriber and provider questions about benefits, eligibility, claims and certification.
• Ensure customer satisfaction and promote a positive corporate public image.
• Screen incoming subscriber and provider calls/inquiries and take data to initiate cases.
• Quote accurate benefit and policy information regarding inpatient and alternative levels of care.
• Handle complicated inquires and educate providers/subscribers in the certification process and reconcile inconsistencies and procedural difficulties when necessary
• Perform all data entry for case initiation and update and enter data into system for non-participating providers.
• Special projects and all other duties as assigned.
• Perform responsibilities and tasks in ways that promote good will, build positive relationships, preserve human dignity, and contribute positively to the corporation service orientation.
• Service calls in a professional and courteous manner.
• Perform review of service requests for complete information.
• Answer telephone calls identifying those needing case management services, those needing referral to routine outpatient services, and those needing authorization and/or verification.
• Answer questions from providers, members, insurance carriers and/or Beacon regional offices.
• Certify benefits per account for specific guidelines.
• Provide a list of in-network providers to callers.
• Explain the benefits and benefit maximums that have been reached.
• Verifies benefits against contract requirements prior to case initiation.
• Refers complicated cases to Case Managers.
• Collect and transfer non-clinical data.
• Acquire structured clinical data.
• Perform activities that do not require evaluation or interpretation of clinical data.
• Attend all staff meetings, team conferences and in-service as directed.
• Comply with all credentialing and other PSO requirements.
• Assist to train new unit personally and to set up new clinical case management units as directed.
• Assist in special projects as directed by the Department Manager/Supervisor.
• Assist clinical area managers to prepare for re-authorization of services by gathering necessary information and retrieving relevant subscriber files.
• Assist to maintain subscribers’ files.
• Assist Clinical Case Managers to complete claims investigations and facilities claims payment by verifying authorizations, verifying member eligibility, and researching provider information.
• Record complaints, grievances, and appeals.
• Collects demographic data from providers/subscribers for case initiation.
• Completes data entry for authorizations.
• Perform data entry for case initiation and updates.
• Research and investigate claims inquiries.
• Document all inquiries.
• Apply Beacon policies and procedures consistently.
• Maintain confidentiality of Clients, Business Records and Reports.
• Maintain ethical and professional standards.
• Maintain individual productivity and performance standards.
• Meet Departmental expectations, accuracy, productivity, and performance standards.
• Support Beacon in achieving Mission Statement.
• Adhere to the components of the Compliance Program.
• Ensure that job tasks are performed in a legal and ethical manner.
• Actively assess work area for non-compliance issues and notify supervisor or call Ethics Hotline.
• Adhere to compliance training requirements and understand that training is required condition of employment.
• Complete tasks accurately and within required timeframes.

Benefits

• We offer a range of market-competitive total rewards that include merit increases, paid holidays, Paid Time Off, and incentive bonus programs (unless covered by a collective bargaining agreement), medical, dental, vision, short and long term disability benefits, 401(k) +match, stock purchase plan, life insurance, wellness programs and financial education resources, to name a few.

What This Job Offers

• Job Type: Full-time
• Career Level: Entry Level
• Education Level: High school or GED
• Number of Employees: 5,001-10,000 employees