Supervisor Provider and Member Service

PHH Peak Health Holdings; West Virginia; Hybrid; USD 65,000 - 95,000; Full time

Job summary

WVU Medicine is seeking a Supervisor of Member and Provider Services to lead the Peak Health call center operations. You will coach telephonic representatives, manage performance metrics, and ensure CMS, ACA, and Medicare compliance while maintaining service excellence.

The role reports to the Manager of Member and Provider Services and requires leadership, process improvement, and alignment with Peak Health's mission of innovative, high-quality healthcare delivery.

Qualifications

• Experience in healthcare call centers or member services is required.
• Leadership or supervisory experience in regulated environments.
• Knowledge of CMS requirements and ACA/Medicare regulations is preferred.

Responsibilities

• Oversees daily department operations to ensure policy adherence and service quality.
• Coaches and develops team members to achieve performance goals.
• Handles escalations from members and providers with timely resolution.
• Ensures compliance with HIPAA and healthcare regulations across processes.
• Collaborates with cross-functional teams to improve service delivery.

Skills

Leadership

Call center experience

Regulatory compliance

HIPAA knowledge

Communication

Education

Bachelor's degree in healthcare administration

Associate's degree in related field

Specialized training in healthcare operations

Tools

SharePoint

Job description

Welcome! We're excited you're considering an opportunity with us!

Below, you'll find other important information about this position. Come join our Peak Health team at WVU Medicine as a Supervisor of Member and Provider Services, helping build the foundation of an innovative and rapidly growing health plan.

Reporting to the Manager of Member and Provider Services, this position plays a critical role in delivering exceptional telephonic service experiences to our members, providers, employer groups, brokers, and community partners.

The Supervisor is responsible for oversight of the day-to-day operations of the Member and Provider Services team, ensuring high-quality telephonic customer service while demonstrating operational excellence, regulatory compliance, and achievement of performance goals.

This role provides direct leadership, coaching, training, and development for telephonic service representatives while fostering a collaborative, member-focused culture.

The Supervisor works closely with cross-functional teams to identify opportunities for process improvement, enhance service delivery, support organizational growth, and advance Peak Health's mission to improve healthcare through innovation, partnership, and exceptional service.

In this unique leadership opportunity, you will help shape the member and provider experience, drive employee engagement and development, and contribute to the continued success and expansion of Peak Health.

Position requires availability Monday through Friday, 8:00 a.m. to 5:00 p.m. during call center operations

MINIMUM QUALIFICATIONS:

1. High school diploma or equivalent AND Three (3) years of experience working in a customer service call center environment AND Four (4) years of experience working in Commercial/ACA, CMS, Medicare, healthcare compliance, health plan operations, member services, or related environments.
2. Associate's degree AND Two (2) years of experience working in a customer service call center environment AND Three (3) years working in Commercial/ACA, CMS, Medicare healthcare compliance, health plan operations, member services, or related environment.

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor's degree in healthcare administration, business administration, management, communications, or a related field.
2. Specialized courses, training, or seminars directly related to Commercial/ACA, CMS regulations, managed care, healthcare compliance, call center operations, leadership, or business management.

EXPERIENCE:

1. Two (2) years of experience in a healthcare, health insurance, or managed care.
2. Two (2) years of experience in a team lead or direct supervisory role overseeing customer service or call center associates.
3. Experience supervising employees in a regulated healthcare, health insurance, Commercial/ACA, CMS, or managed care environment.

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.

1. Oversees daily department operations, ensuring team members consistently follow established policies, procedures, and service standards while maintaining operational efficiency and compliance.
2. Monitor live and recorded member and provider interactions, evaluate individual and team performance metrics, and partner with Team Leads to deliver timely coaching, actionable feedback, and development plans that drive service excellence, quality outcomes, compliance, and achievement of departmental goals.
3. Member and Provider Escalations: Handle complex or escalated inquiries from plan members regarding benefits, claims, or eligibility, and resolve difficult issues for healthcare providers regarding claims, referrals, and reimbursement structures.
4. Ensures departmental operations and member interactions comply with CMS requirements, Commercial ACA, Medicare regulations, Medicaid requirements, HIPAA, organizational policies, compliance standards, and applicable state and federal regulations.
5. Oversees the use of SharePoint and other approved systems to manage team resources and departmental documentation, including updating shared sites, maintaining current policies and procedures, managing access, and ensuring staff can locate required training and reference materials.
6. Demonstrates flexibility in meeting departmental and organizational needs related to changes in call volume, staffing, scheduling, business operations, regulatory requirements, system issues, emergencies, and special outreach initiatives.
7. Identifies on-going continuing education needs of existing employees as well as new employees.
8. Complete annual reviews as well as 90-day review.
9. Keeps staff informed of process, policy and other changes through presentation at regular staff meetings, face to face communication and email correspondence.
10. Participate in meetings with other Peak Health departments to stay current on actions affecting Customer Service and Insurance workflows.
11. Organizes and executes daily tasks in appropriate priority to achieve optimal productivity, accountability, and efficiency.
12. Demonstrates an understanding of healthcare and health plan operations, including eligibility, enrollment, claims, benefits, provider networks, pharmacy coverage, authorizations, billing, grievances, appeals, and reimbursement-related matters.
13. Works with manager to develop and attain quarterly objectives.
14. Demonstrated confidentiality and discretion when interacting with members or about members in compliance with HIPAA and policies and standard set forth by Peak.
15. Demonstrates flexibility to meet the needs of the department or hospital in regard to changes in work volume, planned change, scheduling changes, and emergency call – backs (i.e. weather or disaster).
16. Partners with Quality, Training, and Compliance teams to develop and deliver training, reinforce performance expectations, and address identified knowledge or process gaps. Supports employee onboarding, system access, training, mentoring, and transition to independent call handling.
17. Promotes a professional, collaborative, inclusive, and accountable work environment focused on member experience, regulatory compliance, continuous improvement, and operational excellence.
18. Participates in the recruitment, interviewing, selection, onboarding, and retention of qualified Member Services representatives.

PHYSICAL REQUIREMENTS:

1. Ability to sit, stand, walk, and use standard office equipment for extended periods of time.

WORKING ENVIRONMENT:

1. Exposed to high stress and constant interruptions.
2. Standard office environment.

SKILLS AND ABILITIES:

1. Excellent verbal and written communication skills, including the ability to communicate complex healthcare, Medicare, and regulatory information clearly and professionally.
2. Knowledge of medical terminology.
3. Ability to monitor and interpret call center performance metrics, quality results, productivity measures, and service-level data to identify trends and opportunities for improvement.
4. Excellent Customer Service and telephone etiquette.
5. Strong decision-making, problem-solving, critical-thinking, and analytical skills, with the ability to assess complex situations and determine appropriate actions.

Scheduled Weekly Hours: 40 Shift: Exempt/Non-Exempt: United States of America (Exempt) Company: PHH Peak Health Holdings Cost Center: 2911 PHH Member Services

The West Virginia University Health System is a West Virginia-based academic health system that provides the full continuum of healthcare services at 30 hospitals in West Virginia, Pennsylvania, Ohio, and Maryland. With more than 47,000 employees, of which 7,200 are providers, and $10 billion in total operating revenues, the WVU Health System is anchored by an 890-bed academic medical center and the 150-bed WVU Medicine Golisano Children's Hospital in Morgantown, West Virginia. Together, the Health System's hospitals, clinics, and specialty programs provide a comprehensive continuum of care, ranging from community-based primary and specialty services to highly complex, quaternary care and post-acute care.