Member & Recipient Services Representative (Remote NC, Mon-Fri)

LOCATION: Remote - home based, virtual position. The person in this position must reside in North Carolina or within 40 miles of the NC border.

Work Schedule: Monday - Friday from 9:30am - 6:00pm. This is a 40 hour per week position.

GENERAL STATEMENT OF JOB

The primary purpose of the Member & Recipient Svcs Representative position is to assist individuals to access necessary and appropriate services dependent upon need and/or insurance plan. This job is subject to working holidays and holiday rotation as deemed necessary by the business.

The Member & Recipient Svcs Representative duties include conducting telephonic screenings that include the collection of demographic information, providing choice among available providers, linking callers to appropriate services in a manner that is convenient for the individual, and linkage to a licensed clinician for urgent/emergent services if needed, regardless of the callers insurance plan. The Member and Recipient Svcs Representative is trained in various insurance plans managed by Vaya: Tailored Plan, Medicaid Direct, and State funded Services and what benefits fall within each plan for member or recipient utilization.

The Member & Recipient Svcs Representative is trained to identify indicators that require clinical assistance and decision-making, and to work collaboratively with Member Services Clinicians who handle those clinical responsibilities. The Member & Recipient Svcs Representative will also handle a variety of customer services related calls including, but not limited to: confirming enrollment, accessing services, making referrals to address Social Determinates of Health needs, changing providers, providing general information and linkage to external and external programs as deemed appropriate.

This position requires a high-level understanding of North Carolina's Medicaid system and the ability to use multiple technology systems concurrently while on a live phone call.

Note: This position requires access to and use of confidential healthcare information or protected health information (PHI) as described in laws addressing patient confidentiality, including, but not limited to, the federal HIPAA law, the Confidentiality of Alcohol and Substance Abuse Patient Records law, 42 CFR Part 2, and various state laws. As such, the individual filling this position shall be required to be trained regarding such laws and shall be required to observe those laws in his/her capacity as an employee of Vaya Health. The individual filling this position shall also sign a confidentiality statement as an employee of Vaya Health.

ESSENTIAL JOB FUNCTIONS

Handle telephonic requests for services, respond to member and recipient calls, and provide requested information:

The Member & Recipient Svcs Representative handles telephonic requests for services by linking Vaya members with contracted providers to conduct clinical assessments. For services requests, the Member & Recipient Svcs Representative will inquire about the caller's needs, review and confirm member and recipient eligibility, collect necessary demographic information, offer choice of available providers based upon the consumers request and service needs, and schedule appointments within established access time standards.

The Member & Recipient Svcs Representative will inform a Member Services Manager and/or appropriate Provider Network Development staff of gaps and needs associated with trends that are detected within the services system for timely analysis and resolution.

The Member & Recipient Svcs Representative will be alert to any indicators of risk for immediate referral to a Member and Recipient Services Clinician. For the other Member and Recipient Services calls, the Member & Recipient Svcs Representative will obtain information about the caller's questions or concerns and will provide resolution if possible at the time of the call or provide information about the process and expectations for the timeframe when resolution will occur.

For information calls, this position will provide information about Vaya, the Vaya provider network, community resources, and about Medicaid services in the State of NC. Member & Recipient Svcs Representative shall receive extensive training on customer services skills such as the use of appropriate tone, cadence, inflection, and choice of recovery oriented and/or person-centered wording. To ensure high-quality customer service each caller will be offered the opportunity to complete a Customer Satisfaction Survey at the close of the call. All Member and Recipient Services Representatives must adhere to NCMT Call Grading Rubric provided by NCDHHS.

This position requires a high degree of communication skills with various parties- members, recipients, providers, vendors, community organizations, and legal guardians. The Member and Recipient Svcs Representative will complete warm transfers and linkages to a variety of different parties to assist the caller with correct linkage.

Documentation in the electronic information system:

The Member & Recipient Svcs Representative completes call notes, forms, reports and other documentation as required. The Member and Recipient Services Representative will complete required documentation at the time of call. This position requires a high degree of technical skills with utilization of multiple systems/logins throughout a phone call.

Specialized projects and reviews:

The Member & Recipient Svcs Representative will assist in specialized Member Services Departmental projects as requested by the Member and Recipient Services Managers or Directors, and/or the Vice President of Member and Recipient Services.

Other duties:

Other duties as assigned.

KNOWLEDGE, SKILLS, & ABILITIES

A degree alone does not prepare an applicant for this position. Experience providing mental health, substance abuse services, or intellectual / developmental disabilities are essential. Thorough knowledge of social work principles, techniques, and practices, and their application to our current mental health system is necessary. This employee should have knowledge of individual and group dynamics, and will learn de-escalation of telephonic situations, and a thorough knowledge risk indicators. Considerable knowledge of governmental and private organizations and resources in the community is beneficial. Considerable knowledge of the laws, regulations', and policies that govern LME/MCO operations is beneficial. Skill in establishing rapport with staff/consumers in discussing their issues in a sensitive, supportive and nonjudgmental way is necessary. Ability to establish and maintain effective working relationships with community members and provider agency staff is necessary.

Other skills or abilities required are as follows:

EDUCATION & EXPERIENCE REQUIREMENTS

OR

The Member Services Representative must be qualified as a Qualified Professional according to 10A NCAC 27G .0104.

PHYSICAL REQUIREMENTS

• Close visual acuity to perform activities such as preparation and analysis of documents; viewing a computer terminal; and extensive reading.
• Physical activity in this position includes crouching, reaching, walking, talking, hearing and repetitive motion of hands, wrists and fingers.
• Sedentary work with lifting requirements up to 10 pounds, sitting for extended periods of time.

RESIDENCY REQUIREMENT: The person in this position is required to reside in North Carolina or within 40 miles of the North Carolina border.

SALARY: Depending on qualifications & experience of candidate. This position is non-exempt and is eligible for overtime compensation.

DEADLINE FOR APPLICATION: Open Until Filled

APPLY: Vaya Health accepts online applications in our Career Center, please visit https://www.vayahealth.com/about/careers/.

Vaya Health is an equal opportunity employer.