Member Contact & Navigation Specialist
Department: Member & Provider Services
Reports To: Member Contact & Navigation Manager
Status: Full-Time, Non-Exempt
Hours: Monday – Friday
Supervision: This position does not supervise any other staff
Date Updated: March 2023
Summary: The Member Contact & Navigation Specialist is responsible for increasing member satisfaction by providing professional and accurate responses to incoming inquiries regarding plan benefits, eligibility, claims, transportation, interpreter services, and pharmacy issues. This position maintains an up-to-date and thorough knowledge of PrimeWest Health programs, products, and guidelines and properly documents all calls/contacts as required by department standards in a clear and concise manner. The Member Contact & Navigation Specialist is responsible for providing accurate research and resolution to member issues in accordance with established procedures and referring unresolved issues to the next level and/or appropriate area when necessary. This position properly identifies issues as possible Grievances or Appeals and follows appropriate procedures accordingly. The Member Contact & Navigation Specialist attends all departmental meetings and training sessions and maintains strict confidentiality of all sensitive information. The Member Contact & Navigation Specialist is expected to maintain the following standards with respect to member calls:
- Call production: Handle an average of 11 – 13 inbound calls per hour; complete outbound calls as required Answer speed for inbound calls: Answer an average of 80 percent of all calls in under 30 seconds Hold time for inbound calls: Maintain an average hold time for inbound calls of under 30 seconds Call abandon rate: Maintain a call abandon rate of less than 5 percent
Reporting Accountability This position is responsible for meeting the following regulatory, contractual, or other requirements on behalf of PrimeWest Health:
- Follow all regulatory requirements, including Medicare Managed Care Manuals and Minnesota Department of Human Services (DHS) contracts
Role and Key Responsibilities
Assist the Member Contact & Navigation Manager and PrimeWest Health staff in the following as needed:
- Communicate accurate benefit information Treat every caller with respect and dignity Demonstrate the ability to navigate through the membership system and other PrimeWest Health systems with speed and accuracy in order to serve callers efficiently Demonstrate a superior level of quality customer service when speaking with callers Document all calls/inquiries and include pertinent information Ensure all department policies and procedures are followed Assist with phone coverage during the Medicare open enrollment period (October 1 – March 31, 7 days a week, 8 a.m. – 8 p.m.)
General PrimeWest Health Responsibilities
- Abide by the PrimeWest Health Code of Conduct Comply with all PrimeWest Health policies and procedures Comply with the Health Insurance Portability and Accountability Act (HIPAA) and all other privacy laws Be familiar with building safety procedures and alert maintenance if something requires attention Keep public areas of the department and office neat and clean Conduct other responsibilities and activities as needed and assigned
Professional Competencies
- Knowledge and understanding of all Medical Assistance (Medicaid), Medicare, and privacy rules related to member communication
Educational Requirements and Required Qualifications
- At minimum, an associate degree or three years of experience equivalent to the position requirements. Demonstrated knowledge of, and proficiency in, Word, Excel, and Outlook required. Call center experience is a plus. Flexibility and ability to handle multiple tasks. Demonstrated organizational skills and attention to detail. Ability to work effectively with a variety of people both within and outside of the organization. Excellent verbal and written communication skills. Ability to sit at a desk or computer station most of the time. Ability to occasionally lift and/or carry such articles as file folders and small boxes up to 20 pounds.
Appropriate Licensure and Certification Requirements – N/A
Collaborative Efforts with Other Departments
- Administration Business IT & Claims Administration Care & Population Health Management Corporate Compliance & Auditing Information Systems & Technology Operations Pharmacy Management Quality & Utilization Management
Supervision – N/A
This position description is not to be construed as an exhaustive statement of essential functions or responsibilities.
Alexandria, Minnesota – This position offers the possibility for remote/hybrid work.
PrimeWest Health is an Equal Opportunity Employer Committed to Diversity, Equity, and Inclusion