Member Services Rep III

Leon Health Plan; Florida; In loco; USD 22.000 - 33.000; Tempo pieno

Descrizione del lavoro

LEON Health, Inc. is seeking a Member Services Representative in Florida. The role focuses on connecting with prospective and current members, listening to questions, and delivering clear, concise solutions aiming for first-call resolution.

The candidate will handle high-volume calls, research benefits and claims, and coordinate with internal teams to resolve inquiries. Bilingual English/Spanish fluency is required.

Competenze

• Understanding CMS regulatory requirements and standard operating procedures.
• Minimum of 1 year of experience in a call center within insurance managed care, preferably Medicare HMO.
• Bilingual fluency in English and Spanish.

Mansioni

• Handle a high volume of complex calls and may process correspondence.
• Research accounts, claim history or benefits to identify issues and resolutions; guide callers to the correct department.
• Identify complaints, requests for coverage determinations or appeals, and potential fraud to escalate appropriately.
• Contribute to meeting CMS call center metrics and goals.
• Follow up with callers to provide resolutions as needed.
• Document call reasons and dispositions clearly in the call center system.
• Coordinate with different company functions to ensure timely handling of customer requests.

Conoscenze

CMS regulations knowledge

Call center experience

Bilingual English/Spanish

Formazione

High School Diploma or equivalent

Descrizione del lavoro

Turn every conversation into an opportunity to make a difference. As a Member Services Representative, you’ll connect with prospective and current members, listen to their questions and concerns, and provide clear, concise solutions with a focus on first-call resolution. Bring your communication skills and passion for helping others to a role where every interaction matters.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Professionally handles a high volume of complex calls and may also process correspondence (mail, faxes or written letters).

• Researches accounts, claim history or benefits to identify issues and resolution steps. Identifies the correct department to assist with timely and accurate resolution as needed. Able to explain to the caller any action that is required in order to resolve the inquiry or concern.

• Identifies complaints (grievances), requests for coverage determinations or appeals, and possible fraud, waste or abuse to forward to the correct department for research and resolution.

• Contributes to meeting or exceeding CMS call center metrics and Call center goals.

• Follows up with caller to provide response or resolution steps as needed.

• Clearly documents incoming and outgoing call reasons and dispositions in the call center system.

• Develops and maintains positive customer relations and coordinates with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner.

QUALIFICATIONS

Understanding and ability to apply Centers for Medicare and Medicaid (CMS) regulatory requirements and standard operating procedures.

EDUCATION

High School Diploma or equivalent.

WORK EXPERIENCE

Minimum one (1) yearof experienceworking in a call center in insurance managed care, preferably a Medicare HMO.

LANGUAGE SKILLS

Bilingual English/Spanish fluency.