Member Services Representative II
Location: Pearland Administrative Office
Department: KelseyCare Operations
Job Type: Full Time
Kelsey-Seybold Clinic. Your Doctors for Life.
Since 1949, Kelsey-Seybold Clinic has served its patients with one goal in mind – combine the expertise of physicians in a variety of medical specialties, with the close personal care of a family doctor. Kelsey-Seybold is Houston’s largest community-based physician group, caring for more than 400,000 patients. With 19 clinic locations, we are growing to meet the health care needs of our diverse patient population. Our mission is to provide our team members with exceptional opportunities for professional and personal growth.
Member Service Representatives II provide Concierge Service to members of the healthplan which include providing a high level of service to callers and making outreach calls to members to provide information regarding health plan policies, obtain responses to various required surveys and promote member retention and growth initiatives. Member Service Representatives II resolve inquiries from health plan members, providers, and various customers while consistently exceeding productivity, quality and service standards. Member Service Representatives II have proven ability to quickly learn and put into practice software applications to respond to administrative issues related to health plan operations including claims resolution, premium billing, benefit interpretation, and enrollment issues. Member Service Representatives II handles member and provider calls for all lines of insurance business including Medicare Advantage, Self Funded and Fully Insurance Commercial plans and have demonstrated ability to interpret Medicare and Texas Department of Insurance regulations and related health plan Policy and Procedures.
EDUCATION REQUIREMENTS & EXPERIENCE REQUIREMENTS
(A = basics; B = preferred)
High School Diploma
Associates or Bachelor’s Degree
3-5 years of experience in a health care insurance environment or 1 Year Experience as a Member Service Rep I at KelseyCare Advantage or 6 months – 1 year experience as a KelseyCare Advantage Health Plan Representative or KelseyCare Advantage Sales Coordinator
Knowledge of health care and insurance and the ability to Interpret/Apply Medicare Prescription Drug Benefits, Medical Benefit Interpretation, CMS Regulations, Texas Department of Insurance Regulations and ERISA
Excellent interpersonal skills to interface with physicians and members of the health plan. Strong ability to actively listen to customers, probe for clarification, and provide consultative guidance based upon customers inquiries.
Proven Ability to use a variety of software applications and on line resources
Analytical skills to evaluate problems and recommend alternative solutions
Previous Experience with a call documentation system
Knowledge of Medical Terminology
Ability to Work in a Fast Paced Continuously Changing Environment
Knowledge of CPT and ICD9 Codes
Ability to understand complex oral and written directions and technical information.
Strong knowledge of HMOPOS and TPA Plan Design and Claims Processing
Member Service Representatives must build and maintain productive working relationships with various internal and external customers to solve problems systematically using sound business judgment.
“EPIC” Tapestry Experience
Excellent communication and telephone etiquette, Problem Solving and active listening skills
Representative II are required to pass knowledge testing and maintain positive Quality and Production Scores.