Member Service Specialist

This position is temporary/seasonal through April 2027 and is a remote opportunity with a schedule of M-F, 8am-4:30pm or 8:30-5pm EST.

About the Role

In accordance with the Mission and Guiding Behaviors, the Member Service Representative responds to all consumer inquiries received by phone, in person, or in writing regarding product plan benefits, services, organizational determinations, reconsiderations, complaints, and general inquiries in accordance with the rules and regulations of a Medicare Advantage plan and governing agencies. Implements retention strategies to maintain current membership and improve the quality of care and service.

Responsibilities

• Comply with internal policies, Center for Medicare and Medicaid Services (CMS), Ohio Department of Insurance (ODI), NCQA, and all applicable Federal regulations.
• Develop a thorough understanding of the applicable rules and audit protocols that govern all aspects of consumer service activities and demonstrate the ability to pass audits of activities.
• Engage with consumers to effectively meet or exceed individual and team service performance goals in a manner compliant with all Federal, State, and governing requirements.
• Meet or exceed Federal service level requirements for a Medicare Managed Care call center monitored by CMS or their appointed representatives.
• Receive, interpret, and accurately respond to consumer inquiries, both verbally and in writing, reflecting a positive, compassionate, and affirming manner while ensuring compliance with Federal regulations.
• Outreach to members and providers to close gaps in care, create and maintain relationships, and obtain accurate information.
• Discern the needs of consumers with a commitment to providing the highest level of service possible with measurable outcomes.
• Utilize interpreting services and accurately provide answers to consumers via foreign language interpreters to assist limited English-speaking consumers.
• Achieve and maintain a superior (5-STAR) CMS rating in member/consumer satisfaction.

Requirements

• Minimum of high school education; some college-level studies preferred.
• Customer service experience along with knowledge of governmental agencies and regulations, especially Medicare and the Centers for Medicare and Medicaid Services (CMS).
• Effective communication skills, consumer retention, and strategic thinking.
• Demonstrated knowledge and ability to organize multi-tasks in a high-volume, fast-paced team environment.

Benefits

• Competitive compensation and benefits packages including medical, dental, and vision with coverage starting on day one.
• Retirement savings account with employer match starting on day one.
• Generous paid time off programs.
• Employee recognition programs.
• Tuition/professional development reimbursement starting on day one.
• RN to BSN tuition 100% paid at Mount Carmel’s College of Nursing.
• Relocation assistance (geographic and position restrictions apply).
• Employee Referral Rewards program.
• DailyPay – access to earned wages before payday.
• Opportunity to join Diversity, Equity, and Inclusion Colleague Resource Groups.