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.
Member Services Representative I
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.
Principle duties and responsibilities
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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.
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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.
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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.
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Recognize and understand the difference between calls that require quick resolutions and calls which will require follow-up and handle each appropriately.
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De-escalate situations involving dissatisfied customers, offering patient assistance and support.
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Accurately document all contacts per department standards/guidelines in the Customer Relationship Management (CRM) system.
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Accurately and consistently document (electronic database) and resolve Exempt Grievances (any expression of dissatisfaction that are not coverage disputes, disputed health care services involving medical necessity, or experimental or investigational treatment and that are resolved by the next business day following receipt).
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Interface with Grievance and Appeals, Claims, Enrollment, IT, Network Management, Pharmacy, Authorizations, and other internal departments to provide Service Excellence to our members.
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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.
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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.
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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.
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Manage any issues through to resolution on behalf of the member, either on a single call or through comprehensive and timely follow-up.
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Research complex issues across multiple databases and work with support resources to resolve member issues and/or partner with others to resolve escalated issues.
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Provide education and status on previously submitted pre-authorizations or pre- determination requests for both medical and pharmaceutical benefits.
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Meet the performance goals established for the position in the areas of compliance, efficiency, call quality, member satisfaction, first call resolution, punctuality, and attendance.
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Always maintain a professional level of service to members.
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Always maintain confidentiality of information.
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Consistently support the Alliance’s approach to Service Excellence by adhering to established department and company standards for all work-related functions.
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Interact positively with all Alliance Departments.
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Accurately and consistently document (electronic database) and resolve Exempt Grievances (any expression of dissatisfaction that are not coverage disputes, disputed health care services involving medical necessity, or experimental or investigational treatment and that are resolved by the next business day following receipt).
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Process MS Dept projects
- Serve as a back-up to manage the escalated calls.
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Perform other duties as assigned.
ESSENTIAL FUNCTIONS OF THE JOB
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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.
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Conflict resolution: Resolve member problems/conflicts by convening with other departmental staff as needed.
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Member communications: Create and/or mail appropriate member materials and communications as needed.
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Computer: Perform ongoing data entry which assists in the maintenance of the Member Services department database to ensure data integrity.
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Comply with the organization’s Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.
PHYSICAL REQUIREMENTS
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Constant and close visual work at desk or computer.
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Constant sitting and working at desk.
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Constant data entry using keyboard and/or mouse.
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Constant use of multi-monitor setup
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Frequent use of telephone and headset.
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Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
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Frequent lifting of folders, files, binders, and other objects weighing between 0 and 30 lbs.
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Frequent walking and Standing
Number of Employees Supervised: 0
MINIMUM QUALIFICATIONS:
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Bachelor’s degree or equivalent experience preferred.
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High school diploma, GED required.
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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:
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Minimum one year of direct customer service experience. Call center experience and managed care experience a plus
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Experience determining eligibility for financial assistance, insurance benefits, unemployment and/or other social services programs.
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Demonstrated knowledge expert of AAH Member Services policies and procedures
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Consistent record of meeting, maintaining, or exceeding monthly Departmental performance metrics.
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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.
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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.
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Demonstrated ability to effectively handle the department’s key special projects: Member Portal Request Processing, Kaiser PTE Requests, PCP retroactive and same month requests.
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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):
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Ability to prioritize and adapt to changing situations in a calm and professional manner.
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Ability to maintain composure in stressful situations.
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Excellent problem-solving skills
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Ability to exhibit cooperation, flexibility, and provide assistance when talking to members, providers, and staff.
- Skill in basic data entry
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Ability to type 40 net words per minute: multi-task
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Manual dexterity to operate telephone, computer keyboard equipment.
- Speak English proficiently, clearly, and audibly.
- Memorize and retain information quickly; meet physical requirements
- Spell correctly
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Learn the policies, regulations, and rules applicable to business operations.
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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.
- Excellent phone etiquette and ability to communicate clearly and concisely, both orally and in writing.
- Excellent interpersonal skills with the ability to interact with diverse individuals and flexibility to customize approach to meet all types of member communication styles and personalities.
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Strong verbal and written communication skills.
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Demonstrated ability to quickly build rapport and respond to members in a compassionate manner by identifying and exceeding member expectations (responding in respectful, timely manner, consistently meeting commitments).
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Demonstrated ability to listen skillfully, collect relevant information, determine immediate requests, and identify the current and future needs of the member.
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Must be self-motivated and able to work with minimal supervision
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Must be team-oriented and focused on achieving organizational goals.
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Proficient problem-solving approach to quickly assess current state and formulate recommendations.
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Proficient in translating healthcare-related jargon and complex processes into simple, step-by-step instructions which members can understand and act upon.
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Proficient conflict management skills to include ability to resolve issues during stressful situations and demonstrating personal resilience.
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Ability to work regularly scheduled shifts within the Alliance’s hours of operation including the training period, with scheduled lunches and breaks, flexibility to adjust daily schedules; and to work over-time and/or weekends as needed.
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Medical terminology knowledge preferred
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Ability to work within a broad systems perspective.
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Experience in use of various computer systems software as well as Microsoft Windows, and Microsoft Suite, especially Outlook, Word, Excel.
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Must have reliable and stable internet connection for remote work (50-100 Mbps download speeds).
Employees who interact with members of the public may be required to be tested for Tuberculosis and fully vaccinated against COVID-19 and influenza. Successful candidates for those positions/ classifications may be required to submit proof of vaccination against influenza and/or COVID-19, a negative Tuberculosis test, or request an exemption for qualifying medical or religious reasons during the onboarding process. Candidates should not present proof of vaccination until instructed to do so by the Human Resources department.
SALARY RANGE $22.88-$34.33 HOURLY
The Alliance is an equal opportunity employer and makes all employment decisions on the basis of merit and business necessity. We strive to have the best-qualified person in every job. The Alliance prohibits unlawful discrimination against any employee or applicant for employment based on race, color, religious creed, sex, gender, transgender status, age, sexual orientation, national origin, ethnicity, citizenship, ancestry, religion, marital status, familial status, status as a victim of domestic violence, assault or stalking, military service/veteran status, physical or mental disability, genetic information, medical condition, employees requesting accommodation of a disability or religious belief, political affiliation or activities, or any other status protected by federal, state, or local laws.
