Senior Member Advocate

Position Overview

The Senior Member Advocate is a vital role in ensuring service excellence to Zelis clients and their members. The Senior Member Advocate is proficient in and supports all Preservice Outreach, Balance Bill Resolution, and No Surprises Act assignment categories.  This position requires the ability to act independently within the scope of assigned duties and responsibilities and within established policies and guidelines, the ability to effectively multitask, and to consistently meet or exceed performance standards. The Senior Member Advocate is a subject matter expert for the team.  All job functions will be completed using approved policies and procedures, and system design and technical documentation for all Zelis systems and product offerings.

Preservice Outreach Assignments

• Independently determine appropriate action to resolve inquiries and questions regarding provider outreach requests, provider status, and open case status.
• Respond to inbound calls and self-service request from Plan members, providers, and clients.
• Educate members and providers on health plan and plan payment methodology.
• Negotiate with providers to secure acceptance of health plan reimbursement payment methodology within parameters, guidelines, and protocols set forth by the Health Plan when requested while maintaining professionalism and diplomacy.
• Comply with HIPAA regulations and ensure confidentiality of calls, documents, and other sensitive information.
• Assist in facilitation of Memorandum of Understandings (MOU) or Single Case Agreements (SCA) as required.

Balance Bill Resolution Assignments

• Research and respond to calls, respond to email, fax, or self-service submissions inquiries from Health Plan members, clients, and providers regarding balance bills.
• Acts independently to determine appropriate actions to resolve inquiries and balance billing tasks within established service level indicators in adherence to policies, procedures, protocol, and workflow.
• Educate members and providers on Health Plan and Plan payment methodology and member liability.
• Generate appropriate correspondence and follow-up correspondence as needed ensuring it is free of spelling and grammatical errors.

No Surprises Act Support Assignments

• Assist client with facilitation of Open Negotiations as mandated by CMS guidelines and established policy.
• Communicate with provider and client through email, phone, fax, or US mail ensuring all communication is free of grammatical error. This includes offers, counteroffers, offer and release documents, etc.
• Comply with HIPAA regulations and ensure confidentiality of calls, documents, and other sensitive information.
• Generate the Qualified Payment Amount (QPA) for the claims in Negotiations.
• Upon direction and within parameters established by the Plan, the advocate will work to secure a settlement with the provider.
• If no settlement is reached and the case results in an Independent Dispute Resolution, the Senior Member Advocate will assist the Plan in their response by providing a summary of all offers and counteroffers, access to all correspondence and communications, claim process trail and QPA, redacted documents, and data point analysis as requested.

Qualification and Education Requirements

• High School Diploma/GED required; Associate degree preferred.
• Minimum of three years working in a call center, billing/accounts receivable in a hospital or doctor’s office setting, or healthcare claims adjudication, within a production environment within the healthcare/managed care industry.
• Familiar with various reimbursement methodologies, benefit calculations, and Medicare reimbursement.
• Proficiency in basic computer skills, system applications, databases, etc.
• Understands healthcare insurance principles, products, and concepts.

Location and Workplace Flexibility

We have offices in Atlanta GA, Boston MA, Morristown NJ, Plano TX, St. Louis MO, St. Petersburg FL, and Hyderabad, India. We foster a hybrid and remote friendly culture and all of our employee's work locations are based on the needs of the position and determined by the Leadership team. In-office work and activities, if applicable, vary based on the work and team objectives in accordance with Company policies. 

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