The posting
GENERAL SUMMARY: The Member Services Specialist is primarily responsible for ensuring all members and customers have a positive experience throughout the provision of services by addressing their needs, questions, concerns, etc. Additionally, the Member Services Specialist is responsible for ensuring payer information is validated prior to and during services provision. JOB RESPONSIBILITIES: Enrollment Support (40% Job Effort)
Guide members through the enrollment process. Verifies eligibility prior to enrollment with an understanding and knowledge of acceptable and/or restrictions with insurance to each program. Within 24 hours of a new member chart set-up by Medical Receptionist the Member Services Specialist will validate insurance eligibility with designated source of truth. For new walk-in members: The Member Services Specialist will set up an initial EHR chart and verify/validate insurance eligibility with designated source of truth. On a weekly basis, validate member eligibility and benefit plan for members coming in for future appointments using designated source of truth. Explains coverage details, including co-pays, deductibles, and out-of-pocket maximums to members. Complete a thorough verification of benefits (benefit plan, co-pays/HSA/HRA, co-insurance, prior authorization requirements). Initiates request for initial prior authorization and passes to Quality Management for maintenance.
Claims Processing Assistance (30% Job Effort)
Reconciles member roster with health plan/AHCCCS/Medicare/etc. (Primary Coverage) two times per week. Ensures and verifies member eligibility throughout service provision. Updated member record as needed. Coordinate and work with the claims/billing department to ensure accurate processing of claims. Reviewing and correcting the unbilled services report 2 times per week. Correct all claims/billing discrepancies within 3 business days of notification. Ensure all critical elements are end dated in the EHR, discharge within 24 hours of notification. Reports Health Plan and Claim discrepancies to designated department staff. Discrepancies pertaining to eligibility and payers specifically regarding loss of eligibility.
Referral Management (15% Job Effort)
Responds to all referrals; request additional information when needed. Works with all programs to respond timely to referring programs/coordinators; uploads required documents as directed. Coordinates scheduling of services with program staff.
Administrative Support to Medical Receptionist: (10% Job Effort)
Provide back-up support when Medical Receptionist is on PTO/PSL or when engaging in Supervisor meeting. Schedule appointments and manage calendars for behavioral health providers. Maintain accurate and up-to-date member records in electronic health systems. Handle correspondence, including emails and phone calls, in a professional manner.
Other (5% Job Effort)
Address member concerns, escalating as needed to Subject Matter Expert (S.M.E.) Perform other duties as assigned or necessary as they relate to the general nature of the position. Participates in monthly supervision with State Member Services Manager. Participate in Member Services training as directed by State Member Services Manager. Integrates with Program Staff, participating in Program Team meetings and events, and complies with office and attendance policies. Answering multiline phone system. Maintains an approved schedule, and acceptable level of attendance Other duties as they relate to the general nature of the position
QUALIFICATIONS:
Education and Experience – High school diploma or GED. Two years of customer service experience working in the healthcare industry (medical or behavioral health). Experience with Electronic Health Records preferred. Extensive knowledge of eligibility and referral process.
REGULATORY:
Minimum 21 years of age. Valid AZ DPS Level I fingerprint clearance card (must maintain valid card throughout employment) CPR, First Aid, AED certification, if required (must possess upon hire and maintain throughout employment). Initial current negative TB test result, if required (Employer provides).
Questions about this position? Contact us at [email protected].
