Medicare Member Services Representative

Peak Health; Core (WV); Remote; USD 32,000 - 42,000; Full time

Job summary

PHH Peak Health Holdings is seeking a Member Services Representative to support Peak Health Medicare Advantage members and providers. You will handle inbound calls, research and resolve questions, and perform outbound follow-ups to gather information, ensuring a smooth member experience in a call-center environment.

The role requires attention to detail, strong communication, and familiarity with Medicare processes.

Qualifications

• High School diploma or equivalent.
• 1 year of Medicare claims handling experience.
• Associate degree or greater preferred.
• 3+ years in a fast-paced call environment with processing or customer service experience.
• 2 years’ experience in Medicare benefits and CMS guidelines.
• DSNP experience and Medicare/Medicaid navigation knowledge preferred.

Responsibilities

• Verify member information and address general questions.
• Respond to and resolve issues to ensure efficient member experience.
• Maintain open member communication and perform outreach as required.
• Understand Medicare claims processing and related inquiries.
• Meet production and quality standards and manage work queues.
• Communicate effectively with internal/external staff and escalate when needed.
• Attend required training and maintain accurate documentation.

Skills

Medicare knowledge

Customer service

Phone support

Remote work capability

Education

High School diploma

Associate degree (preferred)

Tools

EPIC

Microsoft Office

Job description

Come join our Peak Health team at WVU Medicine as a Member Services Representative, contributing to the foundation for an innovative, Peak Advantage Medicare plan. The Medicare Membership Services Representative will take inbound calls from Peak Health Medicare Advantage members, and providers answering questions ranging from general information to complex inquires on a wide range of issues. This role will work with management and peers on the Peak team to research and resolve member issues and questions. In addition to taking inbound calls, will make outbound calls to members and providers with issue resolution or to gather further information. Candidates should expect to work an 8-hour shift, between the hours of 7:30 am – 8:00 pm Monday – Friday.

MINIMUM QUALIFICATIONS

EDUCATION, CERTIFICATION, AND/OR LICENSURE

• High School diploma or equivalent

EXPERIENCE

• One (1) year of experience with handling Medicare claims or related experience

PREFERRED QUALIFICATIONS

EDUCATION, CERTIFICATION, AND/OR LICENSURE

• Associate Degree, or greater, in related healthcare field.

EXPERIENCE

• Three (3) plus years’ experience in a fast-paced call environment with processing and/or customer service experience.
• Two (2) years’ experience in Medicare benefits
• Two (2) years’ experience in knowledge of CMS guidelines
• Experience supporting Dual Eligible Special Needs Plans (D-SNP), including working knowledge of Medicaid benefits, care coordination, eligibility requirements, and the integration of Medicare and Medicaid services to support complex member needs.
• Experience assisting members with D-SNP eligibility determinations, enrollment processes, benefit-related inquiries, and navigation of Medicare and Medicaid resources to ensure an exceptional member experience.

CORE DUTIES AND RESPONSIBILITIES

The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

• Verify member information while addressing general questions.
• Responds to and resolves all issues/inquires to assure an efficient and seamless member experience.
• Maintains open channels of member communications doing outreach as required.
• Understanding of Medicare claims processing, and related inquiries.
• Meets all production and quality standards, maintaining work queues according to department standards.
• Effectively communicates with internal and external staff.
• Elevates issues to next level of supervision, as appropriate.
• Ensures accuracy of information gathered and shared on a member’s behalf.
• Attends all required training classes, demonstrating proficiency and ability to learn.
• Other duties as deemed appropriate by the Management Team.
• Maintain accurate documents, including timekeeping records

PHYSICAL REQUIREMENTS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Ability to sit for extended periods of time.
• Ability to answer phone calls for extended periods of time.
• Lifting 10-25 lbs.
• Travel Requirement: 0%-25%

WORKING ENVIRONMENT

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• Standard office environment with electrical equipment (i.e., telephone, personal computer, copier, fax machines, etc.)
• Computer Software/Systems include but not limited to Microsoft Office Professional Suite (Outlook, Word, Excel, Access) Internet Explorer and EPIC

SKILLS AND ABILITIES

• Working Knowledge of administrative and clerical procedures and systems such as word processing and managing files and records.
• Ability to take direction and to navigate through multiple systems simultaneously.
• Excellent written and oral communication, customer service, interpersonal skills, and telephone etiquette.
• Ability to solve problems with predefined methods and guidelines to drive improved efficiencies and customer satisfaction.
• Familiarity with Medical insurance services process.
• Requires exceptional attention to detail, the ability to be organized and to be able to perform multiple tasks simultaneously.
• Ability to work remotely – this includes reliability, self-motivation, focus & time management skills.

Additional Job Description

Scheduled Weekly Hours: 40

Exempt/Non-Exempt:

Shift: United States of America (Non-Exempt)

Company: PHH Peak Health Holdings

Cost Center: 2911 PHH Member Services