Member Services Representative II

Cascade Comprehensive Care; Klamath Falls (OR); On-site; USD 42,000 - 54,000; Full time

Benefits offered by this job

Vacation

Medical insurance

Dental and vision insurance

401(k) pension plan

Job summary

Cascade Comprehensive Care in Oregon is seeking a proactive Member Services Specialist to assist members and providers with inquiries, authorizations, eligibility, and claims status. You will develop and implement policies, train new staff, and ensure accurate data handling while maintaining HIPAA compliance.

The role requires strong communication, multitasking, and customer service skills, with a focus on clear information delivery and professional collaboration within a team-oriented

Qualifications

• High school diploma or GED with 4–6 years of related experience

Responsibilities

• Provides member benefit information in a clear and concise manner.
• Assists members and providers with authorizations, eligibility, claim status, and researches inquiries requiring additional information.
• Develops and maintains Member Services policies, workflows, and desktop processes.
• Provides support and guidance to staff and acts as backup to senior staff when needed.
• Analyzes inquiries to determine resolution steps and serves as first contact for escalations.
• Ensures accuracy of member information and assists with redetermination processes for coverage.
• Speaks with members about benefit coverage and provides guidance as needed.
• Performs provider check runs as assigned.
• Maintains task tracking and notification systems.
• Supports development and maintenance of call scripting documentation.
• Reviews notes to maintain department standards and timely follow-ups.
• Resolves claims, social needs requests, and prior authorization inquiries with prompt follow-ups.
• Documents calls clearly in data systems and initiates welcome calls to new members.
• Provides training to new staff on procedures, tasks, and policy changes.
• Monitors member satisfaction survey results and analyzes data.
• Enters data in various programs requiring accurate typing skills.
• Maintains confidentiality per HIPAA and keeps attendance punctual and reliable.
• Works collaboratively in a team with a spirit of cooperation.
• Communicates effectively under pressure with diplomacy and professionalism.

Skills

Communication skills

Presentation

Persuasion

Negotiation

Customer service

Organizational skills

Team collaboration

HIPAA compliance

Multitasking

Education

High school diploma or GED

Tools

Microsoft Office

Job description

Summary

This position is responsible for interacting with members and providers, analyzing inquiries and providing clear and accurate information in a timely manner. This position is also responsible for maintaining policies and procedures and providing new staff training, and tracking progress by performing the following duties.

• Provides member benefit information in a clear and concise manner.


• Assists members and provider partners with authorizations, assignments, eligibility, claim status, and researches inquiries that require additional information not readily available in the internal or external member data systems.


• Develops and maintains Member Services department policies and procedures, workflows, and desktop processes.


• Provides support and guidance to the Member Services Representative I staff and serves as a backup to the Member Services Representative III, when necessary.


• Analyzes member and provider inquiries and determines steps for resolution and is first level of contact for call escalations.


• Ensures accuracy of member information and assists members with redetermination processes for continuation of coverage.


• Assists members with benefit coverage questions and provides guidance and support for member needs.


• Completes provider check run processes as assigned.


• Develops and maintains task tracking workspaces and notifications.


• Assists in developing and maintaining Member Services call scripting documentation.


• Conducts regular note review of the member services team in the data systems and assists in maintaining department standards.


• Conducts appropriate research and follow-up for prompt resolution of claims, social needs requests, and prior authorization inquiries.


• Relays information to appropriate departments and personnel using established communication procedures and provides timely follow-up and status updates to members as calls are processed and resolved.


• Documents calls in a clear and consistent manner and in the appropriate data systems.


• Initiates welcome touch point calls to new members.


• Provides new staff and ongoing training to include but not limited to, policies and procedures, job tasks and call shadowing, benefit coverage, prioritized list changes and Oregon Administrative Rules (OARs).


• Monitors and analyzes member satisfaction survey results.


• Enters data in various programs requiring proficient and accurate typing skills.


• Balances multiple tasks utilizing excellent organizational skills and prioritizes necessary steps to accomplish tasks timely and accurately.


• Maintains confidentiality and complies with HIPAA rules and regulations.


• Maintains punctual, regular and predictable attendance.


• Works collaboratively in a team environment with a spirit of cooperation.


• Displays excellent communication skills including presentation, persuasion, and negotiation skills required in working with members and coworkers and including the ability to communicate effectively and remain calm and courteous under pressure.


• Respectfully takes direction from manager.

EDUCATION And/or EXPERIENCE

High school diploma or general education degree (GED); and four to six years related experience and/or training; or equivalent combination of education and experience.

Computer Skills

Has advanced basic computer job skills including logging on to systems, ability to communicate by email, ability to compose documents, enter database information, create presentations, download forms, and preserve/backup important data.

We provide a competitive salary and excellent benefits, including vacation, medical, dental and vision insurance, and 401(k) pension plan.

We are an Equal Opportunity Employer.