Member Services Specialist

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 RESPONSIBILITIES:Enrollment Support (40% Job Effort)Guide members through the enrollment eligibility prior to enrollment with an understanding and knowledge of acceptable and/or restrictions with insurance to each 24 hours of a new member chart set-up by Medical Receptionist the Member Services Specialist will validate insurance eligibility with designated source of new walk-in members: The Member Services Specialist will set up an initial EHR chart and verify/validate insurance eligibility with designated source of a weekly basis validate member eligibility and benefit plan for members coming in for future appointments using designated source of coverage details including co-pays deductibles and out-of-pocket maximums to 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 Processing Assistance (30% Job Effort)Reconciles member roster with health plan/AHCCCS/Medicare/etc. (Primary Coverage) two times per and verifies member eligibility throughout service member record as and work with the claims/billing department to ensure accurate processing of and correcting the unbilled services report 2 times per all claims/billing discrepancies within 3 business days of all critical elements are end dated in the EHR discharge within 24 hours of Health Plan and Claim discrepancies to designated department staff. Discrepancies pertaining to eligibility and payers specifically regarding loss of Management (15% Job Effort)Responds to all referrals; request additional information when with all programs to respond timely to referring programs/coordinators; uploads required documents as scheduling of services with program Support to Medical Receptionist: (10% Job Effort)Provide back-up support when Medical Receptionist is on PTO/PSL or when engaging in Supervisor appointments and manage calendars for behavioral health accurate and up-to-date member records in electronic health correspondence including emails and phone calls in a professional (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 in monthly supervision with State Member Services in Member Services training as directed by State Member Services with Program Staff participating in Program Team meetings and events and complies with office and attendance multiline phone an approved schedule and acceptable level of attendanceOther duties as they relate to the general nature of the positionQUALIFICATIONS: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 :Minimum 21 years of 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