The Member Services Representative (MSR) is responsible to connect his/her daily activities to the mission and core values of the organization and provide a positive experience to members, patients, prospective members/patients, providers and internal staff . The Member Services Department is a dynamic department which provides a wide array of services to the organization’s multiple health plans and other AHF business lines and services. The MSR is responsible to deliver services that ensure the member/client and internal/external providers’ positive experience and high retention rates. The MRS is responsible for meeting AHF, AHF MCO of Florida, Centers for Medicare and Medicaid Services (CMS), California Department of Health Care Services (DHCS), Florida Agency for Health Care Administration (AHCA) and various Ryan White funded contractual, regulatory, compliance and quality standards as they related to member services, beneficiary benefits and protections.
The MRS contributes to the organization’s success by effectively executing highly regulated processes, i.e.,
• Enrollment and disenrollment processes,
• Effective call center operations,
• Accurate disbursement of member benefit and service information,
• Effective implementation of the complaint and grievance support processes,
• Timely fulfillment of enrollee materials,
• Continuing education of self in the policies and changing requirements made by the regulatory and accrediting agencies.
Essential Duties & Responsibilities
Includes the following. Other duties may be may be assigned.
• Understand and be able to articulate the organization’s health plans and programs in terms of eligibility requirements for enrollment; benefits, limitations, rules for obtaining care; provider and pharmacy networks; enrollment and disenrollment rules.
• Know where to go to find guidance on enrollee-related issues as they pertain to Member Services.
• Answer incoming calls to the Managed Care Division’s call center and provide timely, accurate and complete information regarding issues listed below in a friendly, compassionate, respectful and friendly manner.
o Health plan benefits, i.e., limits, coverage, referral and authorization requirements, disease management program, case management, etc.
o Enrollee eligibility
o Enrollment and disenrollment procedures and when enrollees can disenroll
o Complaints, grievances and appeals
o Provider and pharmacy networks, i.e., assisting member in finding a specialist of his/her choice
o Enrollee eligibility (for provider calls)
o AHF Healthcare Center services, locations and hours of operation
o AHF Pharmacy services, locations and hours of operation
• Look up enrollee eligibility and demographics in the following systems as needed:
o DHCS Medi-Cal Eligibility System
o CMS’s MARx System
• Triage and “warm transfer” member and provider calls beyond the scope of Member Services, i.e., clinical-related enquiries, to appropriate departments within Division.
• Document enrollee-related calls in Posi-Cap.
• Conduct outgoing calls such as the following:
o Outbound Enrollment Verification (OEV) calls
o “Welcome” calls
o Disenrollment survey
o Other enrollee-specific calls, i.e., verify primary care provider assignment, verification of other insurance coverage, address change, etc.
• Use current CMS-, DHCS- or AHCA-approved scripts for call types that require scripts, i.e., OEV call, “welcome” call, disenrollment survey call, etc.
• Advise the Member Services Manager when enrollee materials are close to running out of stock, or if they are obsolete.
• Issue replacement enrollee ID cards and other enrollee collateral, i.e., EOC, provider directory, and mail when requested by enrollee.
• Enter prospective enrollee leads into Managed Care Sales System.
• Refer Florida Medicaid prospective enrollees who wish to enroll in Positive Healthcare Florida to AHCA’s Choice Counseling or Medicaid Enrollment Broker, depending on enrollee’s county of residence.
• Document incoming complaints and grievances into appropriate complaint and grievance logs.
• Accept, prepare and process requests for member reimbursement for covered services or prescription drugs.
• Book non-emergency transportation for Florida enrollees. Refer California enrollees who request non-emergency transportation to Transportation Coordinator in the UM/CM Department.
• Assist in data collection projects for audits and monitoring reviews.
• Assist with mailing projects as needed.
• Collect mail as Department’s PO Box as needed.
• If assigned, provide Member Services telephonic support in Spanish.
• If assigned, process enrollment request applications pursuant to Member Services Department policies and procedures and within the schedule described therein.
• If assigned, generate enrollee correspondence using current plan year CMS-, DHCS- or AHCA-approved templates related to:
o Enrollment/disenrollment request acknowledgment
o Enrollment/disenrollment confirmation
o “Welcome” letter (Medicaid only)
o Low income subsidy gain, loss or adjustment (Medicare only)
o Grievance/appeal acknowledgement
o Out of the service area move investigation (Medicare only)
o OEV letter (Medicare only)
o Enrollee ID card
o PCP reassignment
o Gym membership activation
o GNC administration
o Other enrollment/disenrollment matters
• If assigned, assemble and new enrollee packets following list of required materials on Department’s “New Enrollment Processing Checklist” and send via US Mail or Federal Express.
• If assigned, generate member roster reports by primary care provider (PCP) assignment and distribute to plan PCPs on a monthly basis with cover letter.
• If assigned, provide backup to Pharmacy Technical Help Desk when necessary to perform the following:
o Override authorization requirement
o Update enrollee demographics
o Update LIS status and cost-sharing information using current CMS information or enrollee-provided Best Available Evidence (BAE)
• If assigned, administer “Health and Wellness” benefit:
o Document enrollee benefit election, i.e., gym membership or GNC merchandise cards in EZ-Cap.
o Initiate enrollee membership at contracted gyms, generate and mail activation letter to enrollee and track/document utilization to reconcile against gym invoicing.
o Track GNC benefit utilization and generate and mail merchandise card cover letters.
• If assigned, track and report Medi-Cal “holds” and follow-up with affected members by telephone or mail.
• If assigned, reconcile non-emergency transportation usage with member benefits.
Participation in AHF Meetings/Committees
Member Service Department Staff Meeting
Managed Care Division Staff Meetings
Other meetings/committees as assigned.
There are no supervisory duties for this position.