Job Details

Member Services Representative I

Hybrid: Applicants must be a California resident as of their first day of employment.

Principal Responsibilities:

Member Services Representatives (MSR) are the first point of contact for our members' primary contact with the Alliance for both routine and complex member issues with the goal of delivering excellent customer service to our customers. The position is responsible for answering a high volume of inbound and outbound calls in a timely manner. Respond to all communications coming into Member Services in the form of email, fax, letters, chat and phone calls. Timely responses to all member communication are essential. Must effectively prioritize and flex the workload as new communication and tasks are submitted. Identify the caller's needs, clarify information, research issues, and provide solutions and/or alternatives whenever possible. Accurately and consistently document all conversations in the electronic database. This position is a liaison between the plan, the provider network, and other community agencies. The MSR positions are flexibly staffed classification and work is expected to be performed minimally at the MRS II level. However, the initial selection will be made at the entry level MSR I. Our more advanced level position of the series is the MSR III who will be required to perform a variety of complex matters.

Member Services Representatives are under the direction of a Member Services Supervisor, Manager and Director, and service our members through our call center as well assisting other departments with responses to member issues by initiating communication between departments to ensure action, cooperation, and compliance of managed care operations.

Principle duties and responsibilities:

• Serve as the primary contact for members, providers and others for questions related to claims, benefits, authorizations, pharmacy, member eligibility and other questions related to Alameda Alliance and provide accurate, satisfactory answers to their inquiries or concerns.
• Respond to and resolve member service inquiries and issues by identifying the topic and type of assistance the caller needs such as benefits, eligibility, claims, behavioral health, and care coordination.
• Answer incoming calls, emails, chats, and other requests for assistance in a timely manner in accordance with departmental performance targets and provide excellent customer service while doing so. May include assisting members in person.
• Recognize and understand the difference between calls that require quick resolutions and calls which will require follow-up and handle each appropriately.
• De-escalate situations involving dissatisfied customers, offering patient assistance and support.
• Accurately document all contacts per department standards/guidelines in the Customer Relationship Management (CRM) system.
• Interface with Grievance and Appeals, Claims, Enrollment, IT, Network Management, Pharmacy, Authorizations, and other internal departments to provide Service Excellence to our members.
• Help guide and educate members about the fundamentals and benefits of managed health care topics, to include managing their health and well-being by selecting the best benefit plan service options, maximizing the value of their health plan benefits, and choosing a quality care provider.
• Intercede with care providers (doctor's offices) on behalf of the member, assisting with appointment scheduling; connect members with internal Case Management Department for assistance as needed.
• Assist members in navigating alamedaalliance.org, the Member Portal, and other health care partner online resources and websites to encourage/reassure them to use self- service tools that are available.
• Manage any issues through to resolution on behalf of the member, either on a single call or through comprehensive and timely follow-up.
• Research complex issues across multiple databases and work with support resources to resolve member issues and/or partner with others to resolve escalated issues.
• Provide education and status on previously submitted pre-authorizations or pre- determination requests for both medical and pharmaceutical benefits.
• Meet the performance goals established for the position in the areas of compliance, efficiency, call quality, member satisfaction, first call resolution, punctuality, and attendance.
• Always maintain a professional level of service to members.
• Always maintain confidentiality of information.
• Consistently support the Alliance's approach to Service Excellence by adhering to established department and company standards for all work-related functions.
• Interact positively with all Alliance Departments.
• Perform other duties as assigned.

Essential Functions of the Job:

• Contacts: Receive, manage, and document telephone calls, emails, and other sources of contacts from members, potential members, and providers, and explain health plan benefits and plan rules. Describe the types of services the Alliance offers to the Member within the managed care system. Provide clarification about issues regarding patient and physician rights and how the plan operates.
• Conflict resolution: Resolve member problems/conflicts by convening with other departmental staff as needed.
• Member communications: Create and/or mail appropriate member materials and communications as needed.
• Computer: Perform ongoing data entry which assists in the maintenance of the Member Services department database to ensure data integrity.
• Comply with the organization's Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.

Physical Requirements:

• Constant and close visual work at desk or computer.
• Constant sitting and working at desk.
• Constant data entry using keyboard and/or mouse.
• Constant use of multi-monitor setup
• Frequent use of telephone and headset.
• Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
• Frequent lifting of folders, files, binders, and other objects weighing between 0 and 30 lbs.
• Frequent walking and standing

Number of Employees Supervised: 0

Minimum Qualifications:

• Bachelor's degree or equivalent experience preferred.
• High school diploma, GED required.
• The ability to speak and understand-bilingual: Spanish/English, Cantonese/English, Vietnamese/English, Tagalog/English are required as designated.
• A bilingual proficiency exam will be administered to ensure the candidate possesses the appropriate skill level to meet requirements. The successful candidate must score 90% or higher.

Minimum Years of Additional Related Experience:

• Minimum one year of direct customer service experience. Call center experience and managed care experience a plus
• Experience determining eligibility for financial assistance, insurance benefits, unemployment and/or other social services programs.
• Demonstrated knowledge expert of AAH Member Services policies and procedures
• Consistent record of meeting, maintaining, or exceeding monthly Departmental performance metrics.
• Consistent track record of documenting Service Requests accurately and clearly and monitoring open Service Requests to ensure responses and closure.
• Consistent record of high quality of work as demonstrated through call and documentation auditing, appropriate Call Disposition coding, as well as an overall acceptable monthly Member Satisfaction Survey result as assessed by Member Services Quality Specialist, MS Trainer and Member Services Supervisor.
• Demonstrated proficiency in current Customer Relationship Management (CRM) tool, phone system software Quality Management Solution, Pharmacy Benefits Management applications (PBM), Interpreter vendor scheduling software, delegate portal solutions and the Alliance's Member portal.
• Demonstrated ability to help members face-to-face in the field and/or at the Alliance offices (walk-ins). Also highly skilled at handling issues related to member bills, transportation set-up and benefit coordination with providers and pharmacy needs.

Special Qualifications (Skills, Abilities, License):

• Ability to prioritize and adapt to changing situations in a calm and professional manner.
• Ability to maintain composure in stressful situations.
• Excellent problem-solving skills
• Ability to exhibit cooperation, flexibility, and provide assistance when talking to members, providers, and staff.
• Skill in basic data entry
• Ability to type 40 net words per minute: multi-task
• Manual dexterity to operate telephone, computer keyboard equipment.
• Speak English proficiently, clearly, and audibly.
• Memorize and retain information quickly; meet physical requirements
• Spell correctly
• Learn the policies, regulations, and rules applicable to business operations.
• Follow instructions, reason clearly, analyze solutions accurately, act quickly and effectively in emergency situations; operate office equipment including computers and supporting word processing, spreadsheet, and database applications.