Member Services Resolution Representative in Cypress, CA at Beacon Health Options

Date Posted: 7/18/2018

Job Snapshot

Job Description

General Summary  

The Member Service Resolution Representative is responsible for determining the root cause of complex and escalated call types and facilitating resolution.  The Resolution Representative will proactively assist Member Service Representatives in servicing all non-routine member and provider inquiries. Resolutions consist of tracking down the core of trending issues that arise within Member Services with the intention of finding a once-and-for-all solution.  This is for all non-routine complex matters.

Essential Functions and Responsibilities

  1. Answers internal & external calls.
  2. Makes outbound calls to customers or clients about detailed account information.
  3. Conducts outreach calls to members and providers.
  4. Assists member service representatives with questions regarding calls from members and providers.
  5. Identifies and prevent potential member and provider concerns.
  6. Reports all new and reoccurring issues to management.
  7. Proactively assists Member Service Representatives with questions and escalated calls.
  8. Assists with claims training for Member Services representatives.
  9. Partners and collaborate with other departments to resolve complex claims issues.
  10. Handles and prioritizes a large workload inventory.
  11. Ability to handle conflicting or competing priorities.
  12. Produces a weekly claims recap that contains updates, changes, issues on claims for Member Services
  13. Documents claims actions by completing forms, reports, logs, and records.
  14. Ensures legal compliance by following company policies, procedures, guidelines, as well as state and federal insurance regulations.
  15. Maintains quality customer service by following customer service practices, responding to customer inquiries.
  16. Stays current with system, product, and service plans and participate in educational opportunities.
  17. Enhances department and organization reputation by accepting ownership for accomplishing new and different requests; exploring opportunities to add value to job accomplishments.
  18. Forwards member and provider complaints per health plan guidelines.
  19. Resolves complex claims issues from members and providers.
  20. Regularly reports to work as scheduled and is prepared to commence work at the start of each shift.  Complete full shift as scheduled on a regular basis.
  21. Adheres to all Beacon policies and procedures and standards of operations.
  22. Completes all required and assigned trainings.
  23. Attend all mandatory company or department meetings.
  24. Report to each scheduled shift and commence work and perform essential job function at the start of each schedule shift.
  25. Displays a positive, constructive, and helpful demeanor that is conducive to a safe and respectful work environment.
  26. Performs special projects and other duties as assigned and required.

Minimum Entry Level Qualifications

  • Education: High School diploma or GED required.

  • Licensures: N/A

Years and Type of Relevant Work Experience:

  • 2+ years of experience working in an office setting within the healthcare industry
  • Experience in claims customer service within a call center environment or experience in claims processing
  • Telephone and computer usage as primary tools to perform job duties