Our client is seeking a compassionate and detail-oriented Medical Member Services Representative to join our dedicated team. This role serves as a vital link between our members and the healthcare services we provide, ensuring a seamless and positive experience. You will be responsible for addressing member inquiries, resolving issues related to benefits and claims, and providing exceptional customer service with empathy and understanding.

Responsibilities:

Member Communication and Support:
Respond to member inquiries via phone, email, and potentially in-person, regarding benefits, eligibility, claims, referrals, and provider networks.
Provide accurate and timely information on healthcare plans, policies, and procedures.
Assist members with understanding their benefits and navigating the healthcare system.
Handle sensitive information with confidentiality and professionalism.
Demonstrate empathy and patience when dealing with members who may be experiencing health-related stress.

Claims and Benefits Processing:
Assist members with claim inquiries, including status updates and explanations of benefits (EOBs).
Verify member eligibility and enrollment information.
Process and document member requests for referrals, authorizations, and other administrative tasks.
Collaborate with claims and billing departments to resolve member issues.
Explain deductibles, copays, and coinsurance to members.

Provider Network Management:
Assist members with locating in-network providers and scheduling appointments.
Provide information on provider specialties, locations, and contact information.
Assist with resolving provider-related issues and concerns.

Documentation and Reporting:
Maintain accurate and detailed records of member interactions and transactions in the system.
Generate reports and provide data as needed.
Follow established protocols and procedures to ensure compliance with HIPAA and other regulations.

Problem Resolution:
Investigate and resolve member complaints and disputes effectively.
Escalate complex issues to appropriate departments or supervisors as needed.
Document all member interactions and resolutions in the system.
Follow up with members to ensure resolution and satisfaction.

Qualifications:

High school diploma or equivalent required; associate's or bachelor's degree in healthcare administration or a related field preferred.  
Minimum of 2-3 years of experience in customer service, preferably in a healthcare or medical setting.
Knowledge of medical terminology, healthcare insurance plans, and claims processing.
Familiarity with HIPAA and other relevant healthcare regulations.
Excellent verbal and written communication skills.
Strong problem-solving and critical thinking abilities.
Proficient in using computer systems and software, including electronic health records (EHR) and customer relationship management (CRM) systems.  
Ability to multitask and prioritize effectively in a fast-paced environment.
Strong attention to detail and accuracy.
Ability to work independently and as part of a team.  
Demonstrated empathy and compassion.

Preferred Qualifications:

Bilingual skills (especially in languages commonly spoken by the patient population).
Knowledge of medical coding.

EEO/AA Employer/Vet/Disabled.

The Know Your Rights poster is available here:
https://www.eeoc.gov/sites/default/files/2023-06/22-088_EEOC_KnowYourRights6.12.pdf

The pay transparency policy is available here:
https://www.dol.gov/sites/dolgov/files/ofccp/pdf/pay-transp_%20English_formattedESQA508c.pdf

For temporary assignments lasting 13 weeks or longer, the Company is pleased to offer major medical, dental, vision, 401k and any statutory sick pay where required.

We are committed to working with and providing reasonable accommodations to individuals with disabilities. If you need a reasonable accommodation for any part of the employment process, please contact your staffing representative who will reach out to our HR team.

AppleOne participates in the E-Verify program in certain locations as required by law. Learn more about the E-Verify program.
https://e-verify.uscis.gov/web/media/resourcesContents/E-Verify_Participation_Poster_ES.pdf

We also consider qualified applicants regardless of criminal histories, consistent with legal requirements. Pursuant to applicable state and municipal Fair Chance Laws and Ordinances, we will consider for employment-qualified applicants with arrest and conviction records. For Los Angeles, CA applicants: Qualified applications with arrest or conviction records will be considered for employment in accordance with the Los Angeles County Fair Chance Ordinance for Employers and the California Fair Chance Act.