Lead Member Services Representative

Lead Member Services Representative

To respond to member and provider calls regarding Plan policies, procedures, membership, eligibility, benefits, and claims, providing the highest level of customer service. In addition to the Member Services Representative duties, the Lead Member Services Representative has a higher level of experience, monitors call queues, assists with training material, and handles complex calls that cannot be resolved by the Member Services Representatives.

Responsibilities

• Works with all departments in order to resolve member issues.
• Monitors calls and provides feedback to the Member Services Representatives on a monthly basis.
• Monitors all call queues to ensure adequate coverage in each queue. Moves Call Center staff from one queue to another as needed.
• Provides backup on phones as needed.
• Assists with training material for Call Center staff.
• Handles complex and lengthy calls that cannot be resolved by the Member Services Representatives.
• Acts as a backup trainer for Call Center staff when the Member Services Trainer is not available.
• Attends and delivers community presentations, orientations, and member intake presentations as needed.
• Educates members and providers on the guidelines and policies of PHC.
• Assesses and resolves problems within scope of authority; escalates unusual questions or problems to higher authority levels.
• Documents all complaints, appeals, and grievances.
• Assists with development of training agendas and materials and provides training and guidance to less experienced and newly hired Member Services / Enrollment staff.
• Responds to provider inquiries regarding eligibility; assists with completion of paperwork for MedImpact and VSP.
• Conducts one monitoring session per Member Services Representative each month and processes feedback as needed.
• Monitors Call Center phone display to ensure consistent call flow and adequate coverage throughout the day.
• Handles Supervisor calls.
• Assists walk-in members.
• Participates in special projects, tasks, and assignments as needed.
• Other duties as assigned.

Qualifications

Education and Experience

High school diploma or equivalent; minimum three (3) years of experience in a managed care or member services environment preferred; or equivalent combination of education and experience.

Special Skills, Licenses and Certifications

Thorough working knowledge of managed care and member services policies and procedures. Excellent understanding of all PHC policies and procedures relating to all aspects of care. Excellent understanding of external agencies that provide services to PHC members. Basic understanding about the Medi-Cal eligibility process. Working knowledge of business software applications. Proficient use of computer keyboard to access data. Bilingual skills in Spanish, Tagalog, or Russian are preferred.

Performance Based Competencies

Good oral and written communication skills. Excellent customer service skills with ability to assess and resolve customer complaints, problems, and issues in an efficient and effective manner. Excellent organization skills with ability to prioritize issues, use good judgment, and handle sensitive issues with tact and diplomacy.

Work Environment And Physical Demands

Ability to use a computer keyboard. More than 80% of work time is spent talking on the telephone and using a computer monitor. When required, ability to move, carry, or lift objects of varying sizes, weighing up to 25 lbs.

All HealthPlan employees are expected to :

HIRING RANGE : $32.51 - $39.01

IMPORTANT DISCLAIMER NOTICE

The job duties, elements, responsibilities, skills, functions, experience, educational factors and the requirements and conditions listed in this job description are representative only and not exhaustive or definitive of the tasks that an employee may be required to perform. The employer reserves the right to revise this job description at any time and to require employees to perform other tasks as circumstances or conditions of its business, competitive considerations, or work environment change.