Member Service Specialist
Shopko Optical, Mount Clemens, MI, United States
Effectively manage member needs and benefits by providing answers to patient questions, process claim adjudication, and manage plan enrollments. Maintain provider relations by creating authorization numbers, complete provider credentialing, maintain contracts, and location updates.
DUTIES AND RESPONSIBILITIES
Answer Member Services queue line in a timely manner. Assist patients with eligibility, benefits, locating stores, and resolving problems
Maintain all providers on CAQH and Gemini for credentialing. Update provider information in software, on directory, and on website. Follow up with providers regarding missing information, record due, and completion of credentialing
Review and research upload errors from retail location. EDI claim through TriZetto. Complete rejection letters and maintain rejection log. Partner with providers to resolve claim errors
Maintain contracts with groups and brokers
Process end of month payout. Review all claims for accuracy, generate appropriate reports, submit affiliate and referral claims to Accounts Payable department for payment. Generate group rate reports and send to Accounts Receivable department for invoicing.
Respond to and troubleshoot with other departments and stores regarding claim and authorization errors
Process remakes, benefit reinstatements, and commission payments
Maintain store programs and support (agent on record)
Develop and maintain standard and shelf pricing
Develop and maintain sales collaterals
Develop and maintain ancillary programs (safety, school grants, etc.)
Assist with health fairs offsite as needed
MINIMUM KNOWLEDGE, EXPERIENCE & SKILLS REQUIREMENTS
High School Diploma or equivalent
Vocational or Technical training – Field of Study: CPC, CBCS, RHIT or similar
Associate degree or bachelor’s degree in business administration, management, communication or related field
Combination of education and/or equivalent work experience in a related field
Knowledge of billing, coding, credentialing, and HIPPA a plus
1-3 years of progressively responsible experience in member services field
0-1 years of supervisory experience
Excellent communication and interpersonal skills, with the ability to build relationships
Exceptional organizational and time management skills, with the capacity to prioritize and manage multiple tasks simultaneously
Strong problem solving and critical thinking skills
Flexibility and adaptability to work in a fast-paced, dynamic environment
Proficiency with MS Office Suite of programs
ESSENTIAL FUNCTIONS & WORK REQUIREMENTS
Ability to effectively communicate at all levels within the organization through written and two-way verbal communication
Able to sit or stand for extended periods of time
Able to operate various office equipment (e.g., personal computer, telephone, fax machine, copier, etc.)
Able to read and write at a high school graduate level
Able to lift 10 to 20 pounds
Able to work normal and/or extended (evenings, nights, and weekends) office hours to meet established deadlines
Able to travel independently to support Company objectives and personal development
These statements are intended to describe the general nature and level of work performed by teammates assigned to this job classification. They are not intended to be an exhaustive list of all responsibilities, duties and skills required.
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DUTIES AND RESPONSIBILITIES
Answer Member Services queue line in a timely manner. Assist patients with eligibility, benefits, locating stores, and resolving problems
Maintain all providers on CAQH and Gemini for credentialing. Update provider information in software, on directory, and on website. Follow up with providers regarding missing information, record due, and completion of credentialing
Review and research upload errors from retail location. EDI claim through TriZetto. Complete rejection letters and maintain rejection log. Partner with providers to resolve claim errors
Maintain contracts with groups and brokers
Process end of month payout. Review all claims for accuracy, generate appropriate reports, submit affiliate and referral claims to Accounts Payable department for payment. Generate group rate reports and send to Accounts Receivable department for invoicing.
Respond to and troubleshoot with other departments and stores regarding claim and authorization errors
Process remakes, benefit reinstatements, and commission payments
Maintain store programs and support (agent on record)
Develop and maintain standard and shelf pricing
Develop and maintain sales collaterals
Develop and maintain ancillary programs (safety, school grants, etc.)
Assist with health fairs offsite as needed
MINIMUM KNOWLEDGE, EXPERIENCE & SKILLS REQUIREMENTS
High School Diploma or equivalent
Vocational or Technical training – Field of Study: CPC, CBCS, RHIT or similar
Associate degree or bachelor’s degree in business administration, management, communication or related field
Combination of education and/or equivalent work experience in a related field
Knowledge of billing, coding, credentialing, and HIPPA a plus
1-3 years of progressively responsible experience in member services field
0-1 years of supervisory experience
Excellent communication and interpersonal skills, with the ability to build relationships
Exceptional organizational and time management skills, with the capacity to prioritize and manage multiple tasks simultaneously
Strong problem solving and critical thinking skills
Flexibility and adaptability to work in a fast-paced, dynamic environment
Proficiency with MS Office Suite of programs
ESSENTIAL FUNCTIONS & WORK REQUIREMENTS
Ability to effectively communicate at all levels within the organization through written and two-way verbal communication
Able to sit or stand for extended periods of time
Able to operate various office equipment (e.g., personal computer, telephone, fax machine, copier, etc.)
Able to read and write at a high school graduate level
Able to lift 10 to 20 pounds
Able to work normal and/or extended (evenings, nights, and weekends) office hours to meet established deadlines
Able to travel independently to support Company objectives and personal development
These statements are intended to describe the general nature and level of work performed by teammates assigned to this job classification. They are not intended to be an exhaustive list of all responsibilities, duties and skills required.
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