Member and Provider Services Specialist

Position Duties & Responsibilities

• Serve as the primary point of contact for members through phone, email, chat, and other communication channels
• Assist members with provider selection, appointment scheduling, referrals, and navigation throughout the healthcare system
• Promote first-call resolution while delivering a personalized, empathetic member experience
• Support provider inquiries regarding member eligibility, benefits, claim status, payment, referrals, prior authorizations, and network participation
• Educate providers on Provider Relations and Network Management processes to resolve provider concerns efficiently
• Verify member eligibility and benefits using Athena, payer portals, and internal systems
• Educate members regarding referral requirements and available in-network resources to improve access and reduce out-of-pocket costs
• Resolve eligibility discrepancies by working directly with health plans or guiding members through corrective actions
• Support claims and billing questions, patient balances, payment options, and payment plan information
• Escalate complex financial or reimbursement issues to Claims or Billing teams while maintaining ownership of the member experience
• Explain claim adjudication, payment determinations, denials, coordination of benefits, and reimbursement processes
• Coordinate with Utilization Management and Clinical Operations to facilitate timely resolution
• Intake and document member and provider complaints, grievances, and appeals accurately and completely
• Maintain compliance with CMS, TDI, NCQA, HIPAA, and Harbor Health policies
• Escalate potential compliance, quality of care, patient safety, or regulatory issues appropriately
• Identify access-to-care concerns and potential network adequacy issues
• Aid members in locating participating providers and obtaining timely appointments
• Escalate network access barriers in accordance with regulatory access standards
• Support members through complex care coordination and navigation needs
• Manage high-volume inbound and outbound phone calls, emails, and written correspondence
• Accurately document all member and provider interactions in applicable systems
• Maintain detailed case notes while ensuring confidentiality of Protected Health Information (PHI)
• Follow approved communication standards while personalizing interactions to meet individual member needs
• Meet established quality, productivity, attendance, and service level expectations
• Demonstrate flexibility in a rapidly evolving healthcare environment
• Participate in ongoing training, coaching, and professional development
• Support continuous improvement initiatives designed to enhance the member and provider experience

Required DESIRED PROFESSIONAL SKILLS & EXPERIENCE

• High School Diploma or equivalent; Associate's or Bachelor's degree preferred
• 2+ years of experience in a healthcare contact center, member services, or provider services role
• Familiarity with health insurance operations including eligibility, benefits, claims, prior authorizations, referrals, and appeals/grievances processes
• Familiarity with CMS, TDI, NCQA, and HIPAA compliance requirements as they relate to member and provider services
• Proficiency with EMR and payer portal systems; experience with Athena a plus
• Exceptional customer service, communication, and active listening skills
• Strong analytical and problem-solving skills with the ability to navigate multiple systems simultaneously
• Strong attention to detail and documentation discipline

Preferred Experience

• In a payvider, integrated delivery system, or health plan environment
• Familiarity with Medicare Advantage, Medicaid, ACA Marketplace, or employer group insurance products
• Experience handling appeals, grievances, or regulatory complaint processes
• Knowledge of medical terminology, CPT/ICD-10 coding, or claims adjudication