Member Advocate

Position Overview

At Zelis, the Member Advocate is a vital role in ensuring service excellence to Zelis clients and their members. The Member Advocate is proficient in and supports all Preservice Outreach, assignment categories. This position requires the ability to act independently, to effectively multitask, and to consistently meet or exceed performance standards. The Senior Member Advocate is seen as the subject matter expert for the team.

Preservice Outreach

• 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
• 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)
• Generates correspondence when required, ensuring that correspondence is free of grammatical and spelling errors.
• Properly document activity and calls
• Update provider database to maintain an accurate listing of provider status, including providers’ acceptance or rejection of the health plan’s payment methodology.

Balance Bill Resolution

• Research and respond to calls, respond to email, fax, or self-service submissions inquiries from Health Plan members, clients, and providers regarding balance bills.
• Act 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.
• Escalate balance bill events as appropriate and guided by established policy.
• Assist Plan members with filling credit bureau disputes.
• Assist members with review of their Explanation of Benefits and calculation of deductible, out-ot-pocket, co-payments, and patient liability.

Skills, Knowledge, and Abilities

• High School Diploma/GED required, associate degree preferred.
• Minimum of three years working in a call center, hospital setting, doctor’s office, or healthcare claims adjudication
• At least three years production environment with established productivity and quality goals with proven performance within the healthcare/managed care industry.
• Familiar with various reimbursement methodologies, benefit calculations, and Medicare reimbursement
• Understands healthcare insurance principles, products, and concepts.
• Excellent communication skills, both verbal and written
• Excellent attention to detail, time management and decision-making skills
• Excellent customer service skills with the ability to maintain professionalism, and diplomacy even during tense situations.

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 applicabl