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.

This position which requires the ability to work as a team player within the Alliance and with external contacts, make sound judgments based on analysis of information, be an effective communicator, active listener and balance advocacy for the member with the policy provisions such as plan policies, EOC, regulatory guidelines, and DMHC/DHCS rules and regulations. The MSR provides courteous, professional, and accurate responses to incoming inquiries regarding network, plan benefits, eligibility, authorizations, plan services and guidelines, as well make decisions with the goal of ensuring member satisfaction and retention. The MSR performs a variety of complex functions and is also responsible for maintaining accurate and complete inquiry/grievance records in the electronic database. Maintains compliance with DMHC regulatory requirements and DHCS contractual obligations. MSR I staff who demonstrate proficiency in meeting, maintaining and exceeding principal performance objectives and metrics may be eligible to be promoted to a Member Services II or III role. Member Services Representative I staff may be eligible for promotion to Member Services Representative II or III positions once they have worked as a MSR I for a minimum of 12 months to be proficient with program and system knowledge in addition to meeting performance matrix requirements.

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
• 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
• 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:

EDUCATION OR TRAINING EQUIVALENT TO:

• Bachelor’s degree or equivalent experience preferred.
• High school diploma, GED required.

MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:

• Minimum one year of direct customer service Call center experience and managed care experience a plus
• Experience determining eligibility for financial assistance, insurance benefits, unemployment and/or other social services
• 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
• 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
• 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
• Demonstrated ability to effectively handle the department’s key special projects: Member Portal Request Processing, Kaiser PTE Requests, PCP retroactive and same month
• 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.

Pay rate range: $22.00-$33.01/hourly