Health Plan Member Services Analyst

Abilis Health Plan

The Member Services Analyst for the Institutional and Institutional Equivalent Special Needs Plan (I/IE-SNP) serves as the primary point of contact for membership operations. This role is responsible for delivering exceptional, person centered service to a uniquely vulnerable population by addressing inquiries related to benefits, authorizations, enrollments, claims, grievances, and appeals in full compliance with CMS regulations and the plan's Model of Care (MOC).

This position collaborates closely with Interdisciplinary Care Teams (ICTs), facility staff, authorized representatives, family members, and internal teams to ensure members concerns are resolved timely.

Member Inquiry & Benefits Navigation

• Provide accurate, timely, and empathetic information on Medicare Advantage benefits
• Assist members and representatives in understanding the plan’s benefits and services.
• Facilitate enrollment, disenrollment, and plan change processes.
• Serve as a liaison between members, authorized representatives, facility nursing and social work staff, and the plan's Interdisciplinary Care Team (ICT) to support care coordination activities.
• Communicate relevant member service issues, unmet needs, or quality concerns to assigned Care Managers or Case Managers for clinical follow-up.
• Assist members and facility staff in understanding prior authorization requirements and status for institutional and ancillary services.
• Route authorization requests to the appropriate Utilization Management team and communicate status updates to requesting parties.
• Maintain complete and accurate records of all member interactions in the plan's CRM or member management system in accordance with CMS and internal documentation standards.
• Adhere to all HIPAA privacy and security regulations in handling Protected Health Information (PHI).
• Complete all required CMS and plan-mandated training on an ongoing basis, including Annual Compliance Training, SNP-specific training, and Medicare Advantage regulations.
• Support audit readiness by ensuring documentation quality and accuracy consistent with plan policies.

Grievances, Appeals & Coverage Determinations

• Intake, document, and process member grievances and appeals in accordance with CMS regulatory timeframes (standard and expedited).
• Explain member rights under the Medicare Advantage Appeals and Grievance process, including the right to request an Independent Review Entity (IRE) review.
• Coordinate with the Medical Management, Claims, and Compliance teams to ensure timely resolution and member notification.
• Track and monitor open cases to ensure adherence to required CMS timelines; escalate as needed.

Member Outreach & Education

• Educate members and facility staff on how to access plan services, how to request care, and how to use the plan's provider network.
• Assist with Annual Notice of Change (ANOC) and Evidence of Coverage (EOC) distribution and answering related questions during open enrollment periods.
• Coordinate and host facility and community member engagement events.

• High school diploma or GED required; Associate's or Bachelor's degree in Healthcare Administration, Social Work, Business, or related field preferred.
• Minimum of 2 years of experience in a healthcare member services, customer service, or health plan operations role.
• Prior experience in a Medicare Advantage, managed care, or long-term care/post-acute environment strongly preferred.
• Strong verbal and written communication skills with the ability to communicate complex benefit information in plain language.
• Demonstrated empathy and person centered communication skills, particularly with vulnerable elderly or disabled populations.
• Proficiency with CRM systems, member management platforms, and Microsoft Office Suite (Word, Excel, Outlook).
• Ability to manage a high volume of contacts while maintaining quality and regulatory compliance.
• Strong attention to detail and organizational skills, with the ability to prioritize and meet strict regulatory deadlines.
• Ability to work collaboratively within a multidisciplinary team environment.