Member Services Representative

Solis Health Plans

11h•Onsite

About The Position

Solis Health Plans is a new Medicare Advantage Company focused on providing transparent, connected, and effective solutions for both members and providers. The company aims to deliver a more personal experience throughout the healthcare journey, supported by a team of expert individuals dedicated to quality service. Solis fosters a culture of collaboration and mutual support, where success is interconnected, and every employee is valued. The company has experienced significant growth, doubling in size and expanding its membership from 2,000 to over 10,000. The Member Services Representative is primarily responsible for delivering quality, professional service to all customers through telephone, written communication, or in-person interactions, in accordance with Plan guidelines.

Requirements

Minimum of High School diploma or equivalent.
Minimum of 1 year healthcare experience is required.
Working knowledge of the Privacy and Security Health Insurance Portability and Accountability Act (HIPAA) regulations.
Excellent communication skills, attention to detail, ability to set priorities appropriately and meet strict deadlines and the ability to manage multiple tasks simultaneously is required.
Excellent listening, interpersonal, verbal and written communication skills with individuals at all levels of the organization.
Excellent computer knowledge is required, including proficient knowledge of Microsoft Office.
Familiarity with healthcare laws, regulations and standards.
Ability to compute basic arithmetic and work with numbers.
Must be patient in dealing with an elderly population and sympathetic to hearing or vision deficiencies.
Ability to work effectively independently, work with very little supervision and in a team environment.
Ability to read, analyze, and interpret technical procedures or governmental regulations.
Ability to effectively present information and respond to questions from groups of managers, clients, customers and the general public.
Ability to define problems, collect data, establish facts, and draw valid conclusions.
Strong decision-making, analytical skills.
Must be self-motivated, organized and have excellent prioritization skills.
Must be able to work well under stressful conditions.
Must be able to work in a fast paced environment.
Fluency in English and Spanish.

Nice To Haves

Preference for plan experience

Responsibilities

Handles telephone, written and in-person inquiries in a courteous, professional, thorough, and timely manner to assure member satisfaction.
Assists callers on inquiries regarding coverage decisions, grievances, appeals, benefit interpretation, eligibility verification, medical group/PCP, explanation of how the plan works and how to utilize services, assists with information regarding referrals or authorizations, member complaints, identification card requests.
Must Report to the Doral HQ.
Responsible for maintaining customer service levels (abandonment rate, speed of answer and service level) within established parameters.
Is knowledgeable on plans benefit, CMS and Plans policies and procedure.
Applies high level of subject matter knowledge to solve a variety of common business issues.
Provides quality services effectively to increase the overall level of customer service and satisfaction as measured by CMS.
Identifies the differences between a Grievance, Appeal or Coverage Decision and process the request through the appropriate channels.
Identify, handle, document and/or route Utilization Management inquiries appropriately.
Identify and document Coverage Determinations.
Documents all inquiries and complaints.
Interacts with other departments about member issues or concerns.
Approaches work in a meticulous and thorough manner, pays attention to detail and follows company scripts.
Manages time effectively and prioritizes tasks to meet deadlines.
Assists customers, family members and others with concern and empathy; respect their confidentiality and privacy and communicate with them in a courteous and respectful manner.
Complies with company policies and procedures and maintains confidentiality of customer medical records in accordance with state and federal laws.
Ensures compliance with all HIPAA, OSHA, and other federal, state and local regulations.
Participates in meetings, trainings and in-service education, as required.
Highly regulated environment.
Time frames to handle issues are in accordance with CMS time frames.
Interacts with members, family members, staff, visitors, government agencies, etc., under a variety of conditions and circumstances.