Member Services Specialist (Bilingual - Spanish)

Astiva Health, Inc; California (MO); On-site; USD 45,000 - 65,000; Full time

Job summary

Astiva Health, Inc., located in Orange, CA, seeks a Member Service Specialist to handle Medicare Advantage inquiries from members and providers, focusing on benefits, enrollment, claims, prior authorizations, and grievances. The role emphasizes high-quality customer service, professionalism, and timely issue resolution.

Responsibilities include handling calls and emails, clearly communicating plan details, maintaining detailed records, and meeting CMS metrics.

Qualifications

• 2+ years of customer service experience.
• Minimum 1+ years’ experience with Medicare Advantage.
• Excellent verbal and written communication skills including active listening and probing techniques.
• Ability to multi-task, manage time and prioritize.
• Ability to document information while on the phone with the member.
• Ability to build rapport with members.
• Fluent in Spanish (verbal and written).

Responsibilities

• Handle inbound and outbound phone calls, emails and other communications with members and providers.
• Clearly identify and act on customer needs to achieve satisfaction.
• Clearly explain all details of the Medicare Advantage Plan to members or providers during calls.
• Understand all aspects of Medicare Advantage including benefits, prior authorization, referrals, claims, enrollment, eligibility, appeals & grievances, and network pharmacy services.
• Provide accurate and complete information using the tools provided.
• Keep detailed written records of each telephone encounter during the call.
• Adhere to CMS call center metrics and performance standards.
• Strive to resolve the member’s issue during the first phone call.
• Go above and beyond to provide exceptional customer service.
• Attend consistently and punctually.
• Other duties as assigned.

Skills

Customer service

Active listening

Spanish fluency

Verbal and written communication

Job description

Astiva Health, Inc., located in Orange, CA is a premier healthcare provider specializing in Medicare and HMO services. With a focus on delivering comprehensive care tailored to the needs of our diverse community, we prioritize accessibility, affordability, and quality in all aspects of our services. Join us in our mission to transform healthcare delivery and make a meaningful difference in the lives of our members.

SUMMARY:

The Member Service Specialist is responsible for answering telephonic inquiries from current and potential members and providers regarding Medicare Advantage benefits, eligibility, enrollment, claims, referral, prior authorizations, appeals & grievances and other related concerns. Our Member Service Specialists ensure customer satisfaction by providing excellent customer service, displaying a desire to help and maintaining a professional demeanor. Member Service Specialists will be expected to maintain quality and performance standards.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Handle inbound and outbound phone calls, emails and other necessary communications with members and providers
• Clearly identify and act on customer needs to achieve satisfaction.
• Clearly explain all details of the Medicare Advantage Plan including procedures, protocols, benefits, and any other necessary information to the member or provider during inbound and outbound calls.
• Fully understand all aspects of Medicare Advantage including but not limited to benefits, prior authorization, referrals, claims, enrollment, eligibility, appeals & grievances, providers networks and pharmacy services.
• Provide accurate and complete information using the tools provided
• Keep detailed written records of each telephone encounter during the call
• Adhere to all call center metrics as set forth by CMS regulation and call center leadership.
• Attempt to resolve the member’s issue completely during the first phone call.
• Go above and beyond to provide exceptional customer service.
• Regular and consistent attendance
• Other duties as assigned

QUALIFICATION REQUIREMENTS:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily, including regular and consistent attendance. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION and/or EXPERIENCE:

• 2+ years customer service experience
• Minimum 1+ years’ experience with Medicare Advantage
• Excellent verbal and written communication skills including active listening and probing techniques.
• Ability to multi-tasks, time manage and prioritize.
• Ability to document information while on the phone with the member.
• Ability to build rapport with members
• Fluent in Spanish (verbal and written)

BENEFITS:

LANGUAGE:

Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups and customers or employees of the organization.

MATHEMATICS:

Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.

REASONING ABILITY:

Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram or schedule form.

EEO/AFFIRMATIVE ACTION STATEMENT:

It is the policy of Astiva Health to provide equal employment opportunities without regard to race, color, religion, sex, national origin, age, disability, marital status, veteran status, sexual orientation, genetic information or any other protected characteristic under applicable law. This policy relates to all phases of employment, including but not limited to recruiting, employment, placement, promotion, transfer, demotion, reduction of workforce and termination, rates of pay or other forms of compensation, selection for training, the use of all facilities, and participation in all company sponsored employee activities. Provisions in applicable laws providing for bona fide occupational qualifications, business necessity or age limitations will be adhered to by the organization where appropriate. Please refer to Standard Operating Procedure 100 for more information about the organization’s Aff…

PHYSICAL DEMANDS:

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. While performing the duties of this job, the employee is frequently required to sit and complete work while on a computer. The employee occasionally is required to stand, walk, use hands to finger, handle or feel, reach with hands and arms, stoop, kneel, crouch or crawl, climb or balance, talk and hear. While performing the duties of this job, the employee is occasionally required to lift or exert force up to 10 pounds.

WORK 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. The noise level in the work environment is usually moderate. Employee signature below indicates the employee’s understanding of the requirements, essential functions and duties of this position.