Member & Recipient Services Representative (Mon/Tue/Fri/Sat)

LOCATION : Remote - home based, virtual position. Must reside in North Carolina or within 40 miles of the NC border.

Work Schedule : 7am - 5 : 30pm on Monday, Tuesday, Friday, and Saturday. This is a 40 hour per week position that works 4 days per week, 10 hours per day.

GENERAL STATEMENT OF JOB

The primary purpose of the Member & Recipient Services Representative position is to assist individuals with mental health, developmental and substance abuse disabilities to access necessary and appropriate services within Vaya provider network.

The Member & Recipient Services Representative will assist consumers, families, and community members who call Vaya Health seeking information about both formal and informal services.

This job is subject to working holidays and holiday rotation as deemed necessary by the business.

The Member & Recipient Services Representative duties include conducting telephonic screenings that include the collection of demographic information, providing choice among available providers and linking callers to appropriate clinical services in a manner that is convenient for the consumer, and linkage to a licensed clinician for urgent / emergent services.

The Member & Recipient Services Representative is trained to identify indicators that require clinical assistance and decision-making, and to work collaboratively with Member Services Clinicians who handle those clinical responsibilities.

The Member & Recipient Services Representative will also handle a variety of customer services related calls including : gathering information regarding complaints and concerns, providing information on community resources providing general appeals process information.

Note : This position requires access to and use of confidential healthcare information or protected health information (PHI) as described in laws addressing patient confidentiality, including, but not limited to, the federal HIPAA law, the Confidentiality of Alcohol and Substance Abuse Patient Records law, 42 CFR Part 2, and various state laws.

As such, the individual filling this position shall be required to be trained regarding such laws and shall be required to observe those laws in his / her capacity as an employee of Vaya Health.

The individual filling this position shall also sign a confidentiality statement as an employee of Vaya Health.

ESSENTIAL JOB FUNCTIONS

Handle telephonic requests for services, respond to consumer / enrollee calls and provide requested information :

The Member & Recipient Services Representative handles telephonic requests for services by linking callers with contracted providers to conduct clinical assessments.

For services requests, the Member & Recipient Services Representative will inquire about the caller’s needs, review and confirm consumer eligibility, collect necessary demographic information, offer choice of available providers based upon the consumers request and services needs, and schedule appointments within established access time standards.

The Member & Recipient Services Representative will inform a Member Services Supervisor and / or appropriate Provider Network Development staff of gaps and needs associated with trends that are detected within the services system for timely analysis and resolution.

The Member & Recipient Services Representative will be alert to any indicators of risk for immediate referral to a Member and Recipient Services Clinician.

For the other Member and Recipient Services calls, the Member & Recipient Services Representative will obtain information about the caller’s questions or concerns and will provide resolution, if possible, at the time of the call or provide information about the process and expectations for the timeframe when resolution will occur.

For information calls, this position will provide information about Vaya, the Vaya provider network and about community resources.

Member & Recipient Services Representative shall receive extensive training on customer services skills such as the use of appropriate tone, cadence, inflection, and choice of recovery oriented and / or person-centered wording.

To ensure high-quality customer service each caller will be offered the opportunity to complete a Customer Satisfaction Survey at the close of the call.

Documentation in the electronic information system :

The Member & Recipient Services Representative will complete the initial portion of the Screening / Client Profile for each telephonic screening and will complete progress notes, forms, reports and other documentation as required.

The Member and Recipient Services Representative will complete required documentation at the time of call. All documentation must be complete at the end of the workday or shift.

Tracking and referral of Individuals with indications of High Risk / Special needs :

The Member & Recipient Services Representative will identify individuals that require a referral to Vaya Complex Care Coordination staff on the basis of indications of high risk and / or special services needs.

This tracking and linkage will ensure positive outcomes to meet the individual’s specific needs.

Specialized projects and reviews :

The Member & Recipient Services Representative will assist in specialized Member Services Departmental projects as requested by the Member and Recipient Services Managers or Directors, and / or the Vice President of Member and Recipient Services.

Other duties :

Other duties as assigned.

KNOWLEDGE, SKILL & ABILITIES

A degree alone does not prepare an applicant for this position. Experience providing mental health, substance abuse services, or intellectual / developmental disabilities are essential.

Thorough knowledge of social work principles, techniques, and practices, and their application to our current mental health system is necessary.

This employee should have knowledge of individual and group dynamics, and will learn de-escalation of telephonic situations, and a thorough knowledge risk indicators.

Considerable knowledge of governmental and private organizations and resources in the community is beneficial. Considerable knowledge of the laws, regulations’, and policies that govern LME / MCO operations is beneficial.

Skill in establishing rapport with staff / consumers in discussing their issues in a sensitive, supportive and nonjudgmental way is necessary.

Ability to establish and maintain effective working relationships with community members and provider agency staff is necessary.

Other skills or abilities required are as follows :

• Knowledge of behavioral health principles, techniques, and practices, and their application to complex treatment and services provision.
• Considerable knowledge of person-centered and recovery philosophies.
• Familiarity with mental health, developmental disability, and substance abuse disorders.
• The ability to remain professionally responsive in an ethical and sensitive manor to individual’s needs throughout the course of the workday / shift.
• The ability to work responsibly and effectively with others for a timely resolution of the caller’s needs.
• The ability to interact professionally and effectively with persons who are upset and who disagree.
• Knowledge of the laws, regulations, and policies which govern human services and utilization management.
• The ability to express ideas clearly and concisely orally and in writing, and to plan and execute work effectively and efficiently.
• The ability to utilize complex telephone and computer systems, and to read and document information electronically.

QUALIFICATIONS & EDUCATION REQUIREMENTS

Bachelor’s degree in a Human Services field and two (2) years of experience working with adults or children with serious psychiatric, chemical dependence or developmental disability in a community mental health center or similar setting;

OR a or a bachelor’s degree in a field other than human services and four (4) years of experience working with adults or children with serious psychiatric, chemical dependence or developmental disability in a community mental health center or similar setting.

The Member Services Representative must be qualified as a Qualified Professional according to 10A NCAC 27G .0104.

PHYSICAL REQUIREMENTS

• Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading.
• Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists and fingers.
• Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time.

RESIDENCY REQUIREMENT : This position is required to reside in North Carolina or within 40 miles of the North Carolina border.

SALARY : Depending on qualifications & experience of candidate. This position is non-exempt and is eligible for overtime compensation.