DeKalb Health
Member Services Representative I / Job Req 872720192
DeKalb Health, Alameda, California, United States, 94501
Overview
Member Services Representative I / Job Req 872720192 (Maintenance) 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 and the primary contact with the Alliance for both routine and complex member issues, with the goal of delivering excellent customer service. Answer a high volume of inbound and outbound calls in a timely manner. Respond to all communications coming into Member Services (email, fax, letters, chat, and phone calls). Timely responses to all member communication are essential. Effectively prioritize and flex the workload as new communications and tasks are submitted. Identify caller needs, clarify information, research issues, and provide solutions and/or alternatives whenever possible. Accurately and consistently document all conversations in the electronic database. Serve as a liaison between the plan, the provider network, and other community agencies. Note: MSR positions are flexibly staffed; work is expected to be performed minimally at the MRS II level. The initial selection will be at the entry level MSR I. The more advanced level is MSR III, who will handle a variety of complex matters. MSRs work under the direction of a Member Services Supervisor, Manager, and Director, serving members through the call center and assisting other departments by initiating communication to ensure action, cooperation, and compliance of managed care operations. Member Services Representative I responsibilities include team collaboration, sound judgment, effective communication, active listening, and balancing member advocacy with policy provisions (plan policies, EOC, regulatory guidelines, and DMHC/DHCS rules and regulations). Provide courteous, professional, and accurate responses to inquiries regarding network, plan benefits, eligibility, authorizations, plan services and guidelines; make decisions aimed at member satisfaction and retention. Maintain accurate and complete inquiry/grievance records in the electronic database; maintain compliance with DMHC regulatory requirements and DHCS contractual obligations. Prospects for promotion to MSR II or III based on performance and tenure. Principal Duties and Responsibilities
Serve as the primary contact for questions related to claims, benefits, authorizations, pharmacy, member eligibility, and other inquiries related to Alameda Alliance; provide accurate, satisfactory answers. Respond to and resolve member service inquiries by identifying topic and type of assistance needed (benefits, eligibility, claims, behavioral health, care coordination). Answer incoming calls, emails, chats, and other requests in a timely manner per departmental performance targets; provide excellent customer service. May include in-person assistance. De-escalate dissatisfied callers with patient, clear explanations and follow-up as needed. Document all contacts per guidelines in the CRM system; document and resolve Exempt Grievances (as defined) by the next business day following receipt. Interface with Grievance and Appeals, Claims, Enrollment, IT, Network Management, Pharmacy, and other departments to provide service excellence. Educate members about managed care basics, benefits, self-service tools, and how to maximize plan value and provider quality. Assist with appointment scheduling and connect members to internal case management when needed. Help members navigate alamedaalliance.org, the Member Portal, and partner resources; encourage self-service usage. Manage issues through to resolution on a single call or through timely follow-up; research complex issues across multiple databases and collaborate to resolve escalations. Provide education and status on pre-authorizations or pre-determination requests for medical and pharmaceutical benefits. Meet performance goals in compliance, efficiency, call quality, member satisfaction, first contact resolution, punctuality, and attendance. Maintain professional service, confidentiality, and adherence to department and company standards. Assist with MS Department projects and back-up escalation handling as needed. Essential Functions of the Job
Contacts: Receive, manage, and document calls, emails, and other contacts; explain health plan benefits and rules; clarify patient and physician rights. Conflict resolution: Resolve member problems by coordinating with other staff as needed. Member communications: Create and/or mail member materials and communications as needed. Computer: Perform ongoing data entry to maintain the department database and ensure data integrity. Compliance: Follow the Code of Conduct and all regulatory, contractual, and internal controls requirements. Physical Requirements
Constant and close visual work at desk or computer; extended sitting; data entry with keyboard/mouse; multi-monitor setup. Frequent use of telephone and headset; frequent verbal and written communication. Frequent lifting of folders, files, binders, and objects weighing 0–30 lbs; frequent walking and standing. Minimum Qualifications
Education or training equivalent to a bachelor’s degree preferred; high school diploma or GED required. Minimum one year of direct customer service experience; call center and managed care experience a plus. Experience determining eligibility for financial assistance, insurance benefits, unemployment, or other social services programs. Demonstrated knowledge of AAH Member Services policies and procedures; track record of meeting/exceeding performance metrics; proficient in CRM tools, PBM applications, scheduling software, and related systems. Demonstrated ability to handle special projects (Member Portal processing, Kaiser PTE, PCP retroactive requests, etc.). Ability to work face-to-face with members in the field or at Alliance offices; capable of handling issues related to member bills, transportation setup, and benefit coordination. Special Qualifications (Skills, Abilities, License)
Prioritize and adapt to changing situations calmly; excellent problem-solving and communication skills; ability to build rapport with members, providers, and staff. Strong data entry, keyboard, and typing skills; English proficiency; ability to explain complex healthcare information simply. Excellent interpersonal and phone etiquette; ability to work with diverse individuals and adapt to different communication styles. Proficient in CRM, call center software, PBM, interpreter scheduling software, portal solutions, and the Alliance Member Portal. Ability to work regular shifts, including training period, with flexibility for overtime and weekends. Medical terminology knowledge preferred; proficiency with Microsoft Windows and Office Suite; reliable internet for remote work (50–100 Mbps). TB and COVID-19/influenza vaccination/testing may be required per onboarding processes. SALARY RANGE $22.88 - $34.33 PER HOUR The Alliance is an equal opportunity employer and makes all employment decisions based on merit and business necessity. We strive to have the best-qualified person in every job. The Alliance prohibits unlawful discrimination based on race, color, religious creed, sex, gender, etc., and protects against discrimination under federal, state, or local laws.
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Member Services Representative I / Job Req 872720192 (Maintenance) 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 and the primary contact with the Alliance for both routine and complex member issues, with the goal of delivering excellent customer service. Answer a high volume of inbound and outbound calls in a timely manner. Respond to all communications coming into Member Services (email, fax, letters, chat, and phone calls). Timely responses to all member communication are essential. Effectively prioritize and flex the workload as new communications and tasks are submitted. Identify caller needs, clarify information, research issues, and provide solutions and/or alternatives whenever possible. Accurately and consistently document all conversations in the electronic database. Serve as a liaison between the plan, the provider network, and other community agencies. Note: MSR positions are flexibly staffed; work is expected to be performed minimally at the MRS II level. The initial selection will be at the entry level MSR I. The more advanced level is MSR III, who will handle a variety of complex matters. MSRs work under the direction of a Member Services Supervisor, Manager, and Director, serving members through the call center and assisting other departments by initiating communication to ensure action, cooperation, and compliance of managed care operations. Member Services Representative I responsibilities include team collaboration, sound judgment, effective communication, active listening, and balancing member advocacy with policy provisions (plan policies, EOC, regulatory guidelines, and DMHC/DHCS rules and regulations). Provide courteous, professional, and accurate responses to inquiries regarding network, plan benefits, eligibility, authorizations, plan services and guidelines; make decisions aimed at member satisfaction and retention. Maintain accurate and complete inquiry/grievance records in the electronic database; maintain compliance with DMHC regulatory requirements and DHCS contractual obligations. Prospects for promotion to MSR II or III based on performance and tenure. Principal Duties and Responsibilities
Serve as the primary contact for questions related to claims, benefits, authorizations, pharmacy, member eligibility, and other inquiries related to Alameda Alliance; provide accurate, satisfactory answers. Respond to and resolve member service inquiries by identifying topic and type of assistance needed (benefits, eligibility, claims, behavioral health, care coordination). Answer incoming calls, emails, chats, and other requests in a timely manner per departmental performance targets; provide excellent customer service. May include in-person assistance. De-escalate dissatisfied callers with patient, clear explanations and follow-up as needed. Document all contacts per guidelines in the CRM system; document and resolve Exempt Grievances (as defined) by the next business day following receipt. Interface with Grievance and Appeals, Claims, Enrollment, IT, Network Management, Pharmacy, and other departments to provide service excellence. Educate members about managed care basics, benefits, self-service tools, and how to maximize plan value and provider quality. Assist with appointment scheduling and connect members to internal case management when needed. Help members navigate alamedaalliance.org, the Member Portal, and partner resources; encourage self-service usage. Manage issues through to resolution on a single call or through timely follow-up; research complex issues across multiple databases and collaborate to resolve escalations. Provide education and status on pre-authorizations or pre-determination requests for medical and pharmaceutical benefits. Meet performance goals in compliance, efficiency, call quality, member satisfaction, first contact resolution, punctuality, and attendance. Maintain professional service, confidentiality, and adherence to department and company standards. Assist with MS Department projects and back-up escalation handling as needed. Essential Functions of the Job
Contacts: Receive, manage, and document calls, emails, and other contacts; explain health plan benefits and rules; clarify patient and physician rights. Conflict resolution: Resolve member problems by coordinating with other staff as needed. Member communications: Create and/or mail member materials and communications as needed. Computer: Perform ongoing data entry to maintain the department database and ensure data integrity. Compliance: Follow the Code of Conduct and all regulatory, contractual, and internal controls requirements. Physical Requirements
Constant and close visual work at desk or computer; extended sitting; data entry with keyboard/mouse; multi-monitor setup. Frequent use of telephone and headset; frequent verbal and written communication. Frequent lifting of folders, files, binders, and objects weighing 0–30 lbs; frequent walking and standing. Minimum Qualifications
Education or training equivalent to a bachelor’s degree preferred; high school diploma or GED required. Minimum one year of direct customer service experience; call center and managed care experience a plus. Experience determining eligibility for financial assistance, insurance benefits, unemployment, or other social services programs. Demonstrated knowledge of AAH Member Services policies and procedures; track record of meeting/exceeding performance metrics; proficient in CRM tools, PBM applications, scheduling software, and related systems. Demonstrated ability to handle special projects (Member Portal processing, Kaiser PTE, PCP retroactive requests, etc.). Ability to work face-to-face with members in the field or at Alliance offices; capable of handling issues related to member bills, transportation setup, and benefit coordination. Special Qualifications (Skills, Abilities, License)
Prioritize and adapt to changing situations calmly; excellent problem-solving and communication skills; ability to build rapport with members, providers, and staff. Strong data entry, keyboard, and typing skills; English proficiency; ability to explain complex healthcare information simply. Excellent interpersonal and phone etiquette; ability to work with diverse individuals and adapt to different communication styles. Proficient in CRM, call center software, PBM, interpreter scheduling software, portal solutions, and the Alliance Member Portal. Ability to work regular shifts, including training period, with flexibility for overtime and weekends. Medical terminology knowledge preferred; proficiency with Microsoft Windows and Office Suite; reliable internet for remote work (50–100 Mbps). TB and COVID-19/influenza vaccination/testing may be required per onboarding processes. SALARY RANGE $22.88 - $34.33 PER HOUR The Alliance is an equal opportunity employer and makes all employment decisions based on merit and business necessity. We strive to have the best-qualified person in every job. The Alliance prohibits unlawful discrimination based on race, color, religious creed, sex, gender, etc., and protects against discrimination under federal, state, or local laws.
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