Medicare Member Services Representative - Peak Health

About the Role

Join the Peak Health team at WVU Medicine as a Member Services Representative, supporting the innovative Peak Advantage Medicare plan. The Medicare Membership Services Representative handles inbound calls from Medicare Advantage members and providers, addressing questions ranging from general information to complex inquiries. The role also involves making outbound calls to resolve issues or gather additional information.

Minimum Qualifications

• Education: High School diploma or equivalent.
• Experience: At least one (1) year handling Medicare claims or related experience.

Preferred Qualifications

• Education: Associate degree or higher in a related healthcare field.
• Experience: Three (3)+ years in a fast‑paced call environment with processing and/or customer service experience.
• Two (2) years experience with Medicare benefits.
• Two (2) years knowledge of CMS guidelines.
• Experience supporting Dual Eligible Special Needs Plans (D‑SNP), including Medicaid benefits, care coordination, eligibility requirements, and integration of Medicare and Medicaid services.
• Experience assisting members with D‑SNP eligibility determinations, enrollment processes, benefit‑related inquiries, and navigation of Medicare and Medicaid resources.

Responsibilities

• Verify member information while addressing general questions.
• Respond to and resolve all issues/inquiries to ensure an efficient and seamless member experience.
• Maintain open channels of member communications and conduct outreach as required.
• Apply understanding of Medicare claims processing and related inquiries.
• Meet production and quality standards, maintaining work queues per department standards.
• Effectively communicate with internal and external staff.
• Elevate issues to the next level of supervision when appropriate.
• Ensure accuracy of information gathered and shared on a member’s behalf.
• Attend all required training classes, demonstrating proficiency and ability to learn.
• Maintain accurate documents, including timekeeping records.
• Perform other duties as deemed appropriate by the Management Team.

Skills and Abilities

• Working knowledge of administrative and clerical procedures, word processing, and file/record management.
• Ability to take direction and navigate multiple systems simultaneously.
• Excellent written and oral communication, customer service, interpersonal skills, and telephone etiquette.
• Problem‑solving using predefined methods and guidelines to improve efficiency and customer satisfaction.
• Familiarity with medical insurance services processes.
• Exceptional attention to detail, organization, and multitasking abilities.
• Ability to work remotely with reliability, self‑motivation, focus, and time‑management skills.

Physical Requirements

• Ability to sit for extended periods.
• Ability to answer phone calls for extended periods.
• Lifting 10–25 lb.
• Travel requirement: 0%–25%.

Working Environment

Standard office environment with electrical equipment (telephone, personal computer, copier, fax machines, etc.). Computer software/systems include Microsoft Office Professional Suite (Outlook, Word, Excel, Access), Internet Explorer, and EPIC.

Schedule

8‑hour shift between 7:30 am – 8:00 pm, Monday – Friday.

Additional Information

• Scheduled weekly hours: 40.
• Employment type: Non‑Exempt (United States).
• Company: PHH Peak Health Holdings.
• Cost Center: 2911 PHH Member Services.