Member & Recipient Services Representative; Remote NC,

Location

Remote – home based, virtual position. The person in this position must reside in North Carolina or within 40 miles of the NC border.

Monday – Friday from 9:30am – 6:00pm. This is a 40 hour per week position.

The primary purpose of the Member & Recipient Svcs Representative position is to assist individuals to access necessary and appropriate services dependent upon need and/or insurance plan. This job is subject to working holidays and holiday rotation as deemed necessary by the business.

The Member & Recipient Svcs Representative duties include conducting telephonic screenings that include the collection of demographic information, providing choice among available providers, linking callers to appropriate services in a manner that is convenient for the individual, and linkage to a licensed clinician for urgent/emergent services if needed, regardless of the callers insurance plan. The Member and Recipient Svcs Representative is trained in various insurance plans managed by Vaya:
Tailored Plan, Medicaid Direct, and State funded Services and what benefits fall within each plan for member or recipient utilization.

The Member & Recipient Svcs Representative is trained to identify indicators that require clinical assistance and decision-making, and to work collaboratively with Member Services Clinicians who handle those clinical responsibilities. The Member & Recipient Svcs Representative will also handle a variety of customer services related calls including, but not limited to: confirming enrollment, accessing services, making referrals to address Social Determinants of Health needs, changing providers, providing general information and linkage to external programs as deemed appropriate.

This position requires a high-level understanding of North Carolina's Medicaid system and the ability to use multiple technology systems concurrently while on a live phone call.

Note:

This position requires access to and use of confidential healthcare information or protected health information (PHI) as described in laws addressing patient confidentiality, including, but not limited to, the federal HIPAA law, the Confidentiality of Alcohol and Substance Abuse Patient Records law, 42 CFR Part 2, and various state laws. As such, the individual filling this position shall be required to be trained regarding such laws and shall be required to observe those laws in his/her capacity as an employee of Vaya Health.

The individual filling this position shall also sign a confidentiality statement as an employee of Vaya Health.

Handle telephonic requests for services, respond to member and recipient calls, and provide requested information:

The Member & Recipient Svcs Representative handles telephonic requests for services by linking Vaya members with contracted providers to conduct clinical assessments. For services requests, the Member & Recipient Svcs Representative will inquire about the caller's needs, review and confirm member and recipient eligibility, collect necessary demographic information, offer choice of available providers based upon the consumer's request and service needs, and schedule appointments within established access time standards.

The Member & Recipient Svcs Representative will inform a Member Services Manager and/or appropriate Provider Network Development staff of gaps and needs associated with trends that are detected within the services system for timely analysis and resolution.

The Member & Recipient Svcs Representative will be alert to any indicators of risk for immediate referral to a Member and Recipient Services Clinician. For other Member and Recipient Services calls, the Member & Recipient Svcs Representative will obtain information about the caller's questions or concerns and will provide resolution if possible at the time of the call or provide information about the process and expectations for the timeframe when resolution will occur.

For information calls, this position will provide information about Vaya, the Vaya provider network, community resources, and about Medicaid services in the State of NC. Member & Recipient Svcs Representative shall receive extensive training on customer services skills such as the use of appropriate tone, cadence, inflection, and choice of recovery oriented and/or person-centered wording. To ensure high-quality customer service each caller will be offered the opportunity to complete a Customer Satisfaction Survey at the close of the call.

All Member and Recipient Services Representatives must adhere to NCMT Call Grading Rubric provided by NCDHHS.

This position requires a high degree of communication skills with various parties- members, recipients, providers, vendors, community organizations, and legal guardians. The Member and Recipient Svcs Representative will complete warm transfers and linkages to a variety of different parties to assist the caller with correct linkage.

Documentation in the electronic…