Member Services Specialist - Tempe, AZ (Open Hearts Tempe)

General Summary

The Member Services Specialist is primarily responsible for ensuring all members and customers have a positive experience throughout the provision of services by addressing their needs, questions, concerns. Additionally, the Member Service Specialist is responsible for ensuring payer information is validated prior to and during services provision.

Job Responsibilities

• Enrollment Support (40% Job Effort)

  • Guide members through the enrollment process.
    • Verifies eligibility prior to enrollment with an understanding and knowledge of acceptable and/or restrictions with insurance to each program.
      • Within 24 hours of a new member chart set-up by Medical Receptionist the Member Services Specialist will validate insurance eligibility with designated source of truth.
        • For new walk-in members: The Member Services Specialist will set up an initial EHR chart and verify/validate insurance eligibility with designated source of truth.
          • On a weekly basis, validate member eligibility and benefit plan for members coming in for future appointments using designated source of truth.
            • Explains coverage details, including co-pays, deductibles, and out-of-pocket maximums to members.
              • Completes a thorough verification of benefits (benefit plan, co-pays/HSA/HRA, co-insurance, prior authorization requirements).
                • Initiates request for initial prior authorization and passes to Quality Management for maintenance.