Member Services Representative

SUMMARY

The role also supports authorization processing, eligibility verification, missed trip resolution, and mileage reimbursement activities, while maintaining adherence to KPIs, performance standards, and departmental guidelines. Responsibilities include confirming transportation appointments, conducting quality checks, supporting required controls and training, completing member outreach through outbound calls, and administering customer satisfaction. In addition, providing operational support to the Contact Center by assisting with member transportation services and related workflows.

DUTIES & RESPONSIBILITIES

· Serve as a primary point of contact for members, providers, and health plan partners regarding non‑emergency medical transportation services.

· Perform outbound calling to members, providers, and facilities to confirm trip details, resolve escalations, conduct follow ups, and address eligibility, authorization, or reimbursement issues.

· Manage and respond to inquiries through all Member Services Inboxes and Jira Ticketing Tracking system, ensuring timely and accurate resolution in accordance with contractual SLAs.
· Maintain compliance with Medicaid and Medicare regulations, HIPAA requirements, and contractual health plan guidelines.

· Monitor and resolve missed trips for designated health plan partners, conducting outreach and documentation as required.

· Prepare and maintain timeliness and performance reports for assigned health plan partners.

· Serve as a liaison for Mileage Reimbursement programs, including:

· Ensure accurate documentation of all member interactions, authorizations, and escalations within internal systems (Jira, Epic Ride, etc.)

· Educate members on covered versus non‑covered benefits, reimbursement procedures, and required documentation.

· Collaborate with internal departments, transportation providers, NEMT Alivi Call center and health plan representatives to resolve complex cases and escalations.

· Demonstrate professionalism and empathy while handling high volume calls, sensitive situations, and complex member concerns.

· Monitor and uphold assigned Key Performance Indicators (KPIs), including adherence, timeliness, accuracy, and outbound call volume expectations.

· Verify member eligibility across all contracted Medicaid and Medicare health plans, ensuring services are rendered appropriately.

· Process and manage transportation authorizations, for contracted health plans:

· Review, approve, and coordinate meals, lodging, and ancillary service requests in compliance with health plan policy and benefit guidelines.

REQUIREMENTS & QUALIFICATIONS

PREFERRED QUALIFICATIONS

· Bilingual (English / Spanish) is desirable.

· Associate’s degree or some college coursework in healthcare administration, business, social services, or a related field (Preferred)

· 3 years related experience, or equivalent combination of education and experience.

· Ability to work independently and as a member of cross functional teams.

· Versatility, flexibility, and a willingness to work within constantly changing priorities.

· Technical Proficiency

· Ability to manage priorities and workflows.

· Ability to understand and follow written and verbal instructions.

· Ability to deal effectively with a diversity of individuals at all organizational levels

REQUIRED QUALIFICATIONS

· High School Diploma or GED (Required)

· Good judgement with the ability to make timely and sound decisions.

· Acute attention to detail.

· Commitment to excellence and high standards.

· Strong interpersonal skills

· Excellent verbal and written communication skills.

· Strong organizational, problem-solving, and analytical skills