Job Description

Summary Description:

The Member Service Representative (MSR) III is commonly the initial contact point for members, providers and others who contact Western Health Advantage. The MSR III is responsible for answering incoming contacts and assisting them in resolving issues and/or questions they may have. This may involve interaction with other internal departments or external entities such as Medical Groups, Health Care Providers, and/or Brokers. In addition, the MSR III is responsible for resolving complex/high-level issues and/or concerns regarding health plan benefits, policies, and procedures and assists the Senior MSRs when needed.

Representative Duties:

• Respond to all member inquiries related to Commercial, Exchange and/or Individual plans via telephone, email, chat, or fax.

• Provide service to any walk-in members on an as needed basis.

• Support other Member Service Representatives by answering questions/clarifications regarding plan rules/policies, benefits, and/or system information.

• Research and resolution of cases that require additional investigation; including, when necessary, cases that involve urgent access to care or involve the Member Relations Unit.

• Provide training and call shadowing of new MSRs.

• Assist members, providers, brokers, and plan partners with claims-related billing questions and issues as needed.

• Work with inter and intra-department staff to help resolve member issues to ensure resolution within prescribed timeframes.

• Educate members on the Advantage Referral Program, Western Health Advantage’s website, and the self-service tools available to them online.

• Accurately record and refer appeals and grievances according to department protocols and procedures.

• Meet department standards related to performance and attendance.

• Manage difficult or emotional customer situations, respond promptly to customer needs, solicit customer feedback to improve service, respond to requests for service and assistance, and meet commitments.

• Report any system problems or call drivers needing immediate attention to Member Service Supervisor or Manager immediately.

• Attend meetings regarding any system upgrades and/or changes and present information to the department as needed.

• Use tact, discretion, and courtesy while interacting with clients, the public, and other encounters in the course of work.

• Perform other duties and special projects as assigned.

Qualifications:

• High School Diploma.

• 3 years’ experience working in a call center with increased responsibilities.

• Previous experience working in the health care industry, specifically HMO, is a plus.

• Intermediate computer skills, including electronic mail, routine databases, word processing, spreadsheet, graphics, etc.

• Must be able to speak, read, write, and understand the primary language(s) used in the workplace

Salary:

$23.00 to $25.00 hourly DOE

Western Health Advantage is committed to providing equal employment opportunities to employees and applicants for employment on the basis of merit and without regard to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, age, physical or mental disability, medical condition, genetic information, marital status, ancestry, military or veteran status, or any other basis made unlawful by federal or state law. EOE

Western Health Advantage values and supports the unique talents and strengths that each employee brings to our organization. Collaborating with the best and the brightest means a dynamic, fulfilling work experience for you — and excellent customer service for our members.

*WARNING: Please beware of phishing scams that solicit interviews or promote work-at-home opportunities, some of which may pose as legitimate companies. Please be advised that Western Health Advantage will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the to the Federal Trade Commission by selecting the ‘Rip-offs and Imposter Scams’ option.’

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