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NationsBenefits is recognized as one of the fastest-growing companies in America and a Healthcare Fintech provider of supplemental benefits, flex cards, and member engagement solutions. We partner with managed care organizations to provide innovative healthcare solutions that drive growth, improve outcomes, reduce costs, and bring value to their members.
Through our comprehensive suite of innovative supplemental benefits, fintech payment platforms, and member engagement solutions, we help health plans deliver high-quality benefits to their members that address the social determinants of health and improve member health outcomes and satisfaction.
Our compliance-focused infrastructure, proprietary technology systems, and premier service delivery model allow our health plan partners to deliver high-quality, value-based care to millions of members.
We offer a fulfilling work environment that attracts top talent and encourages all associates to contribute to delivering premier service to internal and external customers alike. Our goal is to transform the healthcare industry for the better! We provide career advancement opportunities from within the organization across multiple locations in the US, South America, and India.Purpose
The Member Services Representative is responsible for handling routine member and provider inquiries regarding benefits, claims, eligibility, and general health plan information. This role requires a working knowledge of health plan systems, products, policies, procedures, and departmental functions to effectively assist members and providers while delivering excellent customer service.
Essential Functions
• Answer inbound calls from members and providers regarding health plan benefits, claims, eligibility, and general inquiries.
• Research, locate, and provide accurate information while ensuring a positive customer experience.
• Resolve member service issues by identifying concerns, researching solutions, implementing appropriate resolutions, and escalating complex issues when necessary.
• Review and analyze claims to identify key elements and processing requirements based on diagnosis codes, procedures, provider information, medical policies, contracts, and established polices and procedures.
• Educate members and providers on benefits, coverage, and health plan processes.
• Identify members who may benefit from care management or managed care interventions and collaborate with clinical staff to facilitate appropriate services.
• Document all interactions accurately and thoroughly in accordance with company policies and regulatory requirements.
• Maintain compliance with HIPAA and all applicable healthcare regulations.
• Meet productivity, quality, attendance, and customer satisfaction standards.
Knowledge, Skills, and Abilities
• Strong computer and data entry skills.
• Previous call center or customer service experience preferred.
• Working knowledge of Medicare and Medicaid programs preferred.
• Excellent verbal and written communication skills.
• Strong problem-solving and critical-thinking abilities.
• Ability to multitask and navigate multiple systems simultaneously.
• Attention to detail and commitment to accuracy.
• Ability to work independently and as part of a team.
• Professional demeanor with a strong focus on customer satisfaction.
Education and Experience
• High School Diploma or GED required.
• Minimum of one (1) year of customer service or call center experience preferred.
• Healthcare, insurance, Medicare, or Medicaid experience preferred.