Member Services Specialist

Intermountain Centers•Tucson, AZ

About The Position

The Member Services Specialist ensures members and customers have a positive experience throughout the provision of services by addressing their needs, questions, and concerns. The role also ensures payer information is validated before and during service provision. The position supports member enrollment and insurance eligibility verification, explains benefit coverage, assists with prior authorization requests, and helps reconcile claims and billing information. It also manages referrals and scheduling, maintains accurate electronic health records, provides administrative backup to the Medical Receptionist, and responds to member concerns. The specialist participates in supervision, training, program team meetings, and events, and follows office and attendance policies.

Requirements

High school diploma or GED.
Two years of customer service experience in the healthcare industry, medical or behavioral health.
Minimum age of 21.
Valid Arizona DPS Level I fingerprint clearance card, maintained throughout employment.
CPR, First Aid, and AED certification upon hire and maintained throughout employment, if required.
Initial current negative TB test result, if required; the employer provides the test.

Nice To Haves

Experience with Electronic Health Records.
Extensive knowledge of eligibility and referral processes.

Responsibilities

Guide members through enrollment and verify eligibility before enrollment, including understanding insurance acceptance and restrictions for each program.
Validate insurance eligibility for new member charts within 24 hours of setup and create initial EHR charts and validate eligibility for new walk-in members.
Validate member eligibility and benefit plans weekly for members with future appointments.
Explain coverage details, including co-pays, deductibles, and out-of-pocket maximums, and verify benefit plans, co-pays, HSA/HRA, co-insurance, and prior authorization requirements.
Initiate requests for initial prior authorization and pass them to Quality Management for maintenance.
Reconcile member rosters with health plans, AHCCCS, Medicare, and other primary coverage sources twice per week.
Ensure and verify member eligibility throughout service provision and update member records as needed.
Coordinate with the claims and billing department to support accurate claims processing.
Review and correct the unbilled services report twice per week and correct claims or billing discrepancies within three business days of notification.
Ensure critical elements are end-dated in the EHR and complete discharge within 24 hours of notification.
Report health plan and claim discrepancies to designated department staff, including eligibility and payer discrepancies related to loss of eligibility.
Respond to referrals, request additional information when needed, upload required documents as directed, and coordinate service scheduling with program staff.
Provide backup support for the Medical Receptionist during PTO/PSL or supervisor meetings.
Schedule appointments, manage behavioral health provider calendars, and maintain accurate member records in electronic health systems.
Handle correspondence, including emails and phone calls, professionally, and answer a multiline phone system.
Address member concerns and escalate them to a Subject Matter Expert when needed.
Participate in monthly supervision with the State Member Services Manager and in training as directed by that manager.
Integrate with program staff by participating in program team meetings and events, and comply with office and attendance policies.
Maintain an approved schedule and acceptable attendance, and perform other duties related to the general nature of the position.