Member Experience Specialist

Job Summary
The Member Experience Specialist will work independently to seek to improve the member experience for their dedicated clients by engaging with members to identify and uncover needs and providing solutions that will enhance their health and wellness through phone and digital communication. They should proactively identify potential issues ensuring the organization is consistently providing exceptional member service.

Essential Functions

• Relationship management:
  -Responsible for designing member solutions for clients, engaging directly with WebTPA POD and assisting client's Human Resource's team members
• Design and execute proactive member engagement outreach strategies
• Eligibility responsibility, managing and troubleshooting Client EDI files and ensure eligibility implementation is finalized by established dates
• Serve POD members as concierge support:
  -Initiate claims investigation, negotiate settlements, interpret medical records, respond to Department of Insurance complaints, and authorize payment to claimants and providers
  -Serve as the immediate escalation resource for customer service reps and claims examiners
  -Responsible for claims processing and adjudication, researching claims where applicable
• Provide member service:
  -Inbound and Outbound proactive outreach to members, as determined by the MES utilizing client data and analytics
  -Resolve member issues routed through member calls
  -Triage and escalate member issues to the necessary department when appropriate
  -Engage with members to ensure previous issues have been resolved in a timely manner
  -Support members and providers to the best experience in addressing OON facility services, provider billing challenges
  -Maintain good rapport with physicians, healthcare facilities, clients, providers and internal and external stakeholders
• Review and process insurance to verify medical necessities and coverage under policy guidelines (clinical edit logic)
• Utilize systems to track complaints and resolutions
• Responsible for basic POD reporting and analytics demonstrating POD level performance for clients

Qualifications

• 1+ years related work experience.
• Related Bachelor's degree or additional related equivalent work experience
• Strong proficiency with Microsoft Office.
• Strong verbal and written communication skills; ability to tailor communications based on audience and business objectives.
• Comfortable working and communicating at very high levels across operational areas and working in cross-functional teams
• Maintain confidentiality and observe HIPAA requirements
  Strong customer service skills.
• Ability to work independently/autonomously and proactively as well as collaboratively as a member of a team.
• Self-starter with the ability to identify problems/issues and offer workable solutions.
• Ability to prioritize or seek information on how to best prioritize projects.
• Project confidence, high energy, enthusiasm, and high regard for client advocacy and service

Preferred Qualifications

• One to three years' experience in the health insurance administration industry a plus.

General Physical Demands
Sedentary work: Exerting up to 10 pounds of force occasionally to move objects. Jobs are sedentary if traversing activities are required only occasionally.

Physical/Environmental Activities
Must be able to travel to multiple locations for work (i.e. travel to attend meetings, events, conferences). Occasionally

We are an Equal Opportunity/Protected Veteran/Disabled Employer committed to creating a diverse, inclusive and equitable culture for our employees and communities.