Member Services Representative

Position Summary:

Solis Health Plans is looking for a Member Services Representative primarily responsible for providing quality, professional service to all customers when calls are received through the Member Services Department via telephone, written or in-person in accordance with Plan guidelines.

Essential Duties and 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.

Qualification and Education:

• Minimum of High School diploma or equivalent.
• Minimum of 1year healthcare experience is required, with a preference for plan experience.
• 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.