Member Services Specialist

Member Services Specialist

South Country Health Alliance located in Medford, MN, has an immediate opening for a full- time Member Services Specialist at our Medford location.

The Member Services Specialist serves as the primary point of contact in our call center. The Member Services Specialist assists members telephonically with issues involving enrollment, transportation, benefit questions, coverage limits, payments, claims, and those matters that involve provider networks.

The position hours are from 8 a.m. - 4:30 p.m. M-F, with flexibility to work additional hours, including limited weekends during open enrollment (October thru March) and holidays.

Requirements include a High school diploma or equivalent. At least one year
of practical experience in customer service or call center is also required.
Preferred: Bilingual; Post high school education in business; Healthcare or insurance experience;
Knowledge of Medicaid and Medicare rules.

South Country offers a full range of comprehensive benefits and competitive pay. View full position
description below and text MSS to 507-565-6775 to apply!

This position is a grade 3 and starts at $18.50/hour

POSITION DESCRIPTION (Non-Exempt)

Position Title: Member Services Specialist

Dept.: Operations Department

Reports To: Member Services Manager

Date: March 2024

Skill Set: Computer savvy and proficient in the use of Microsoft Office Suite and Chrome in
order to navigate and retrieve information from a variety of software and internet applications,
including numerous third party administrator (TPA) systems; Self-directed, highly organized and
very detail oriented in completing multiple assigned tasks simultaneously; Conversational with a
variety of personality styles; High level of patience to work with a diverse caller group; Good
written communication skills to document calls in a clear and concise manner; Excellent verbal
communication skills and enjoy working with the public via telephone for extended periods of time;
Adaptable to a continually changing environment and able to maintain a high degree of
confidentiality.

Education/Experience: Required: High school diploma or equivalent. At least one year
of practical experience in customer service or call center required.
Preferred: Bilingual; Post high school education in business; Healthcare or insurance experience;
Knowledge of Medicaid and Medicare rules.

Basic Function
As the primary point of contact in our Call Center, the Member Services Specialist provides
accurate information and assistance to members involving enrollment, transportation, benefit
questions, coverage limits, payments, claims, and those matters that involve provider networks.
This may be over the phone or in person.

Essential Job Duties
1. Provides assistance to members with questions, concerns, and complaints they may have regarding
their enrollment, benefits, and/or services provided by South Country in a professional and
efficient manner that allows members to receive exceptional service and accurate information.

2. Participate in the day-to-day RideConnect program to effectively schedule member transportation
requests. This may include intaking requests, verification of appointments, identification
of the most cost-effective provider, outreach to providers to check availability, book rides,
confirm rides with members, coordinate ride modifications, ride cancellations, and other tasks
necessary to coordinate transportation.

3. Utilize and navigate multiple computer systems, including a cloud-based phone system, to provide
service to our members. Procedures and workflows are followed accurately
and completely.

4. All interactions are documented (calls, emails, and face to face conversations) in a CRM
software to ensure that any audit, follow-up communication, grievance or appeal can be handled in
an accurate, appropriate, and timely manner.

5. Assist Community Care Connectors (CCC) and other county staff with benefit questions, location
of network providers, pharmacy issues, member materials, etc. in order that members are provided
the best continuum of care possible.

6. Be aware of, or be able to obtain, Federal, State, and County laws and rules that regulate the
provision of health care services to South Country members, including those that apply to enrollee
Grievances and Appeals, in order that South Country and its employees are in compliance with such
laws and rules and that members suffer no loss of coverage.

7. Determine when an issue needs to be escalated to supervisor or other management personnel.

8. Perform other duties as assigned within the scope, responsibility, and requirements of the job.

Qualification Requirements:

To perform this job successfully, an individual must be able to perform each essential duty
satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or
ability required. Reasonable accommodations may be made to enable individuals with disabilities to
perform the essential functions.

Language Skills:

Must be able to read and write in English. Knowledge of Spanish and/or Somali languages a plus.
Ability to access interpretation services, if needed.

Mathematical Skills:

Basic mathematical skills required.

Accuracy:

It is critical for the Member Services Specialist to communicate accurate information to enrollees
regarding their healthcare benefits. The impact of errors or negligence in communicating incorrect
information/benefits could be significant. In these instances, members could miss or be late for
their medical appointments, and South Country could incur costs of paying claims for inaccurate
services not in the member’s benefit set. Quality checks may identify these errors, but this would
be during a retro review.

Reasoning Ability:

Must be able to draw conclusions from past practice, essential information, rules and regulations,
and common sense. Requires the use of judgment to research and make decisions in communicating
benefits. Problem solving may be of a more challenging degree.

Physical demands:

The physical demands described here are representative of those that must be met by an employee to
successfully perform the essential functions of this job. Reasonable accommodations may
be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to talk or listen. The
employee frequently is required to sit for lengthy periods of time. The employee is occasionally
required to stand, walk; use hands to finger, handle, or feel objects, tools, or controls; and
reach with hands and arms.

The employee must occasionally lift and/or move up to 10 pounds. Specific vision abilities
required by this job include close vision, distance vision, peripheral vision, depth perception,
and the ability to adjust focus.

Work Environment:

The work environment characteristics described here are representative of those an employee
encounters while performing the essential functions of this job. Reasonable accommodations may be
made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee should encounter no unusual or hazardous
conditions. The noise level in the work environment does vary depending on call volume and number
of member services staff on duty.

Travel Requirements:

This position has limited exposure to out-of-town travel but may be required to occasionally
travel.

Contacts:

The Member Services Specialist obtains specific cooperation from personnel regarding work received
from another or work delivered to another. This position has constant contact with enrollees, both
via telephone and face-to-face, and works closely with the community care connectors, specific
internal staff, as well as several TPAs and has occasional contact with providers.

The Member Services Specialist will communicate with members in a professional, courteous manner
that will build trust, enabling the enrollee to have full confidence that they are receiving the
correct information regarding their benefits. Based upon their experience assisting enrollees in
solving benefit issues or concerns, this position will help to develop policies and procedures that
can be used as guidelines when similar situations arise in the future.

Financial Impact:

Errors in communicating benefits to members could negatively impact South Country at a moderate to
significant level depending on the individual situation. If a Member Services Specialist indicates
to a member that a service is covered, but it really is not, South Country
could incur the costs of paying those claims.