Description
Job Title: Member Services Representative
Department: Operations – Member Services
About the Role:
ApolloMed is looking for a Member Service Representative to join our fast and growing Dynamic team.
You are:
Comfortable with ambiguity and biased towards action
Relentlessly resourceful
Growth-oriented
Mission-driven
What You’ll Do:
Answer all daily telephone calls from members, providers, health plans, insurance brokers, collection agents and hospitals
Collect Elicit information from members/providers including the problem or concerns and provide general status information
Verify authorization, claims, eligibility, and status only
All calls carefully documented into Company’s customer service module & NMM Queue system
Member/Provider Service/Representative assists Supervisor and Manager with other duties as assigned
Member outreach communications via mail or telephone
Assist Member appointment with providers
Resolve walk-in member concerns
Able to provide quality service to the customers
Able to communicate effectively with customers in a professional and respectful manner
Maintain strictest confidentiality at all times
Specialist termination notifications sent to members
Urgent Medicare Authorization Approval – Notification to Medicare members
Transportation arrangement for Medicare & Medi-Cal members
Outreach Project Assignments
Inbound Calls:
Member/Provider/Health Plan/Vendor/Hospital/Broker:
All calls carefully documented into Company’s customer service module
Annual Wellness Visit (AWV) – Gift card pick up and schedules
Appointment of Representative (AOR) for Medicare Members
Attorney / Third Party Vendor calls
Authorization status/Modification/Redirection/CPT Code changes/Quantity adds/Explain Denied Auth/Peer to Peer calls/Extend expired auth/Pre-certified auth status/Retro/2ndor 3rd opinion/
Conduct 3 way conference call to Health Plan with member
Conference call with Providers – Appointments, DME,
COVID – 19 related questions (Tests & Vaccines)
Direct Member Reimbursement (DMR)
Eligibility – Demographic changes: Address/Phone/Fax Changes/Name change
Escalated calls from providers/members
Health Diary Passport
Health Source MSO – Assist & arrange inquiries on Eligibility/Change PCP/Benefit with AHMC
HIPPA Consent – Obtain Member Consent verification
Inquiries on provider network/provider rosters
Lab locations
Member & Provider Complaints/Grievances
Member bills
Miscellaneous calls
Pharmacy – Drug/medication pick up and coverage
Provide authorization status for Hospital /CM Dept
Self-Referral Request for Medicare
Return Mail
Track Mail Packages/ Certified mail status
Translations – Spanish / Chinese
Urgent Care / locations/ operations hours
Outbound Calls:
Member/Provider/Health Plan/Vendor/Hospital/Broker:
Assist Case Management on CCS – age in 21 years for change of PCP from Pediatrics to FP/IM
Assist Marketing on email inquiries
Assist PR/ Elig – Members assigned to wrong PCP/with no PCP status
Assisted UM / Medical Directors on urgent member appointment from escalated cases
Authorization status response call back
Benefits – return call once information is obtained / verified
Complaints/Grievances – return calls once resolution is obtained
DME – Translation support in Spanish and Chinese to confirm item / appointment set up for DME department
Eligibility – return call to providers/labs when member is added to system while waiting at the office.
Member bills – return calls once resolution is obtained
Member Survey – Annually: every 4thquarter
Outreach project from internals – QCIT
Resolve walk in members concerns
Specialist Termination notification sent to members
Transportation arrangement for Medicare / Medi-Cal members
Voice mail – return calls back to callers
Concierge Services – Essential Responsibilities
Assist to contact new members/IPA member transfer on new PCP assignment as needed
Work group discussions on work status/progress on new member/IPA transfer
Update call log and provide daily/weekly status as needed
Facilitate members with complex pre-existing conditions, medications, PCP/SPC network reviews
Conference call with PCP selection / change
Help member to identify member bill status, connect provider with on billing and claim submission
Responsible for experience of the membership associated with new member/IPA transfer
Responsible for to interact with Health Plan’s Customer Service Team to serve new member/IPA transfer
Problem Solving complex cases/ brain storm with MS management team for resolution
Minimum qualifications:
High School Diploma or GED
Experience using Microsoft applications such as Word, Excel and Outlook
Experience working in customer service
One year related experience and/or training; or equivalent combination of education and experience.
You’re a great for this role if:
You have previous work experience working in a healthcare setting
You are Bilingual in Mandarin/Cantonese or Spanish