Member Services Representative



The Member Services Representative will be directly responsible for answering incoming provider and member phone calls regarding claims, eligibility, benefits, and payment inquiries. Bilingual in English/Spanish is a plus. The Member Services Representative will also serve as support to the Claims Processor (as needed). Responsibilities include, but are not limited to, monitoring and adjudicating medical, dental, and vision claims and ensuring timely processing and payment of claims.

The Member Services Representative will have talent and experience in both customer service and/or claims processing and will be expected to take part in both daily position responsibilities (listed below), as well as various team projects. The Member Services Representative is expected to be a team player, therefore, a good attitude and strong work ethic are imperative, as well as excellent communication skills both written and verbal. The Member Services Representative will report to the Member Services Team Lead.

Position Responsibilities

• Provide customer service regarding claims, eligibility, benefits, and payment inquiries

• Process Medical, Dental, and Vision claims utilizing ICD-9 and CPT codes

• Ensure timely submission and payment of all Medical, Dental, and Vision claims

• Review medical billing and coding, perform various data entry tasks, and file documents

• Provide customer service support regarding claims, eligibility, and payment inquiries

• Manage claim files (locate/request files, file claim documents, reconstruct missing files, transfer misfiled documents, etc.)

• Retrieve, print, fax, or mail supporting documentation to providers or others as directed following strict HIPAA protocol.

• Provide backup for any support functions in the office

• Receive, screen, and route incoming telephone calls and other electronic correspondence

• Contact or receive contact from customers or other authorized third parties to obtain and/or provide necessary file information to comply with quality and process standards

• Generate and send appropriate forms to claimant for completion

• Complete all necessary forms, log documents into the system, and route them to the appropriate parties

• Maintain HIPAA compliance and confidentiality at all times and protect all personal health information (PHI) as it relates to patient data

(Download Job Description PDF below)