Member Services Processing Specialist

This is a fully remote position, open to applicants in United States.

📋 Description

• Review, assess, and process member applications, certifications, transfers, appeals, appointments of designated representatives, documentation, and service requests.

• Take ownership of the complete processing of enrollment applications, certifications, transfers, appeals, designated representative appointments, and updates to member records.

• Examine materials submitted by members for completeness, accuracy, and eligibility.

• Identify follow-up actions and coordinate with members, providers, and internal stakeholders.

• Evaluate documentation against the criteria for program enrollment and certification.

• Recognize edge cases and suggest resolution pathways.

• Utilize digital mail center systems, intake/entry portals, and intelligent document processing platforms to triage, route, and process documentation.

• Keep case notes and processing records for audits, compliance reviews, and operational analytics.

• Collaborate with supervisors and cross-functional teams to address complex situations and enhance workflow efficiency.

• Track backlog, turnaround time, accuracy rate, and other operational metrics.

• Contribute to corrective actions and initiatives for continuous improvement.

• Escalate unclear or high-risk cases with thorough documentation and rationale for decisions.

• Aid in quality assurance by identifying trends and factors contributing to errors.

• Engage in cross-training for enrollment, record updates, appeals routing, designated representative processing, and member correspondence.

• Apply policies and standard operating procedures with judgment, identify exceptions, and suggest resolution options.

• Prioritize tasks based on risk criteria and service levels.

• Propose process enhancements and assist in updating standard operating procedures.

• Participate in the validation and testing of new procedures or tools as they are introduced.

⛳️ Requirements

• High School Diploma or equivalent.

• 1–3 years of experience in processing, administrative support, data entry, customer service, or related operations.

• Excellent written and verbal communication skills.

• Ability to adhere to detailed procedures, meet deadlines, and adjust to changing priorities.

• Proven analytical skills with a keen eye for detail.

• Capability to assess documentation against established program requirements.

• Experience supporting federal health programs or healthcare operations is preferred.

• Familiarity with intelligent document processing tools, member service portals, or customer support platforms is preferred.

• Exposure to HIPAA-regulated environments and knowledge of handling PII/PHI is preferred.

• US citizenship is not required.

• Must manage PII/PHI in compliance with HIPAA and program privacy standards.

• Must adhere to security and access controls.

🏝️ Benefits

• Full-flex work week to manage your priorities at work and home.

• 401K with company matching.

• Comprehensive health and wellness packages.

• An internal mobility team focused on helping you advance your career.

• Opportunities for professional growth, including paid education and certifications.

• Access to cutting-edge technology for learning.

• Paid vacation and holidays.

• Medical plan options, including those with Health Savings Accounts.

• Dental plan options.

• Vision plan options.

• Paid time off encompassing vacation, sick leave, personal time, holidays, parental leave, military leave, bereavement leave, and jury duty leave.

• Typically 15 days of paid leave each calendar year.

• 10 paid holidays annually.

• Up to 160 hours of paid family leave in a rolling 12-month period for eligible employees.

• Short- and long-term disability benefits.

• Life insurance coverage.

• Accidental death and dismemberment insurance.

• Personal accident insurance.

• Critical illness insurance.

• Business travel and accident insurance.

• Identity verification process utilizing advanced biometrics and artificial intelligence.