Customer Engagement - Representative, Member Serv I

The hiring company is confidential. The Member Service Representative I handles member and client inquiries, resolves service issues, supports claims processing, and assists with enrollment and billing transactions.

Responsibilities:

• Answers member inquiries by clarifying desired information; researching, locating, and providing information. Resolves member service problems by clarifying issues; researching and exploring answers and alternative solutions; implementing solutions; escalating unresolved problems
• Examines claims to identify key elements, and processing requirements based on diagnosis, procedures, provider, medical policy, contracts, and policy and procedures. Calculates deductibles, maximums, and determining resolving, reporting, and following through on overpayments, underpayments, and managed care processes
• Learns and executes enrollment transactions in accordance with contractual and medical underwriting guidelines, generating accurate billing for policies and products purchased by new clients, existing clients, and transfers from other Client Plans. Learns the details of offering and administering various billing transactions, i.e. direct pay, credit card payment, and debit accounting through the policyholders checking account, and how to effectively interact with or advise clients, group administrators, brokers, or providers on problem resolution
• Identifies clients who are eligible or in need of managed care interventions and collaborates with the clinical professionals in designing and implementing the intervention
• The incumbent uses knowledge of products and the contractual provisions that govern administration to provide client education, to interpret contract data and business rules to clients for the purpose of supporting client business and member support objectives through telephone communication, or written correspondence. Documents all client interactions according to established procedures
• Examines member records to identify key elements, and processing requirements based on established business rules policies and procedures. Researches, investigates, and resolves problems related to member data or records and communicates resolution clearly and effectively
• To effectively interact with clients, the incumbent must develop and apply an expert ability to analyze client needs. Responds to telephone and written inquiries from internal and external customers regarding contract data
• Provide support for the execution of enrollment transactions in accordance with contractual and medical underwriting guidelines for new clients, existing clients, and transfers to and from other Client and Non Client Plans. Learns the details of offering and administering various enrollment transactions and how to guide various customers regarding problem resolution
• Learns to access information from FEPOC automated systems, and by telephone and written inquiry with various clients. Responds to client inquiries
• To effectively administer service, the incumbent must utilize a range of automated systems including but not limited to FEPDirect, NICE, OnBase, Advance Capture, etc

Requirements:

• Education Level: High School Diploma or GED
• Experience: 1 year customer service, claims experience, Inbound Call Center Experience
• Self-starter with strong organizational skills and planning skills
• Ability to maintain effective interpersonal relationships
• Ability to recognize, analyze, and solve a variety of problems
• Excellent communication skills both written and verbal
• Maintains quality customer services by following customer service practices; responding to customer inquiries
• 2-5 Years inbound call center experience
• Possess a passion for Customer Service
• Innovative thinking and drive for results
• Display exceptional oral and written communication skills
• Possess independent, self-starter skills required to be a dependable and productive remote agent
• Capability to navigate concurrently between multiple software systems with relative ease
• Ability to interface with a culturally diverse population
• Working knowledge of basic computer functions including Microsoft products, internet research and email communication
• Work experience in a Quality/Production driven environment
• Position requires performance in either service or claims for a minimum of 18 months at a meets standard level or above
• Must have previous customer service and/or claims experience
• Additional required experience includes use of automated systems, PC or CRT proficiency, excellent oral and written communication skills, time and organizational management, and successful project management
• Experience performing duties that are detailed in nature, exposure to health care, health insurance, medical information, and direct service experience is preferred