Medicare Member Relations Representative

Why Choose Jefferson Health Plans?

We are an award-winning, not-for-profit health maintenance organization. We are committed to creating a community where everyone belongs, acknowledges, and celebrates diversity and has opportunities to grow to their fullest potential.

We offer Medicaid, Medicare, and Children’s Health Insurance Program (CHIP) plans that include special benefits to improve the health and wellness of our members. We’re also committed to boosting the health of our community through outreach, education, and events. Founded over 35 years ago, Jefferson Health Plans continually develops new ways to encourage better health outcomes and has received national recognition for our innovations in managed care.

While this job currently provides a flexible remote option, due to in-office meetings, training as required, or other business needs, our employees are to be residents of PA or the nearby states of DE or NJ.

Perks of Jefferson Health Plans and why you will love it here:

• Competitive Compensation Packages, including 401(k) Savings Plan with Company Match and Profit Sharing 
• Flextime and Work-at-Home Options
• Benefits & Wellness Program including generous Time Off 
• Impact on the communities we service. 

We are seeking a talented and enthusiastic Member Relations Representative to join our team!

The Medicare Member Relations Representative (Tier 1) promotes a positive image of Jefferson Health Plans via telephone, utilizing each contact as an opportunity to educate members and providers about the plan, effectively handling inbound, outbound and outreach calls to and from members, providers, and other areas internal and external to Jefferson Health Plans. This role requires a basic understanding of the concepts of Medicaid, Medicare and CHIP lines of business and demonstrating skills in assisting the members/providers with the reason for the call as outlined in the primary responsibilities or escalating the call as appropriate to the Tier II level of agents. Ensure member retention as well as advise them of specific eligibility requirements to assure continued customer satisfaction.

As the Member Relations Representative your daily duties may include:

• Educate members and providers about Jefferson Health Plan with the intent of retaining members and providing a high level of customer service.
• Respond to member and member-related calls in a courteous, professional & efficient manner providing timely follow-up to requests for information and service.
• Answer eligibility and benefits questions, assuring that members receive service, use the plan correctly and gain a high level of satisfaction with the plan.
• Assist members with demographic changes, updates or as required coordinating the changes with the County Assistance Office, CMS, Office of CHIP or the Department of Health and Human Services.
• Assist members and providers with registering on the member/provider portal and basic self service functions.
• Assist with requests for ID cards, Welcome Kits, member handbook, provider directory or any other printed material that can be mailed out.
• Assist with PCP changes and scheduling initial doctor appointments.
• Collaborate or escalate with internal departments to facilitate resolutions to member’s issues and concerns.
• Conduct targeted telephonic outreach to members using a prepared script depending on Manager’s direction.
• Open or build new cases in the care management system and route to the appropriate staff following the direction of the Team Leader, Supervisor or Manager.
• Research members’ demographics in regulatory system and build cases in Member Relations documentation system by calling hospitals, PCP offices, and/or home care agencies to locate a member’s most recent phone number.
• Schedule and coordinate transportation need.
• Utilize the Member Relations translation vendor as indicated by the needs of the member.
• Refer members to the appropriate Nurse Advice lines and appropriate programs.
• Maintain accurate data entry into designated software systems.
• Promote partnership with Quality Management (QM), Utilization Management (UM), Care Coordination, Healthcare Economics and Special Needs Unit (SNU).
•  Maintain call records, logs and other documentation in accordance with departmental requirements.
• Escalate trends and issues which impact the membership for immediate resolution.
• Operate all applications and telephone systems effectively and efficiently, following established protocols for security, transfer and information exchange. 
• Participate in appropriate staff meetings and training sessions, reporting on trends and issues which impact members and Jefferson Health Plans as a whole.
• Attend monthly meetings as scheduled.
• Adhere to daily schedule, responding to emails timely, use of appropriate call center status, confidentiality of information, and general business protocols.
• Perform other clerical and support tasks as assigned. 
• Other duties as assigned.

Qualifications

• High School Diploma or 3 years of Equivalent work experience required.
• Excellent communication and interpersonal skills required.
• Minimum of 1+ years of call center experience, inbound/outbound telephone experience or equivalent face to face customer service experience preferred.
• Healthcare experience is preferred. Managed care experience is a plus.

 Skills, We Value:

• Excellent written and verbal communications skills.
• Bilingual a plus
• Basic typing and computer skills required. Experience using Microsoft Word and Excel is desirable.
• Ability to work independent of direct supervision, but also must be able to work within a Team.