Member Services Processing Specialist

Accountabilities

• • Member application processing: Process enrollment applications, certifications, transfers, appeals, designated representative appointments, updates, and other service requests in accordance with program policies, standard operating procedures, and federal requirements.
  • Documentation review: Examine member-submitted documentation for completeness, accuracy, eligibility, and compliance, determining whether materials satisfy applicable program requirements.
  • Data entry and case management: Enter and update information accurately within member services systems, digital mail center tools, entry portals, and intelligent document processing platforms, ensuring documentation is properly routed and processed on time.
  • Case documentation: Maintain accurate case notes, records, and supporting documentation to facilitate program reviews, compliance requirements, and audit readiness.
  • Member and stakeholder support: Communicate professionally with members, healthcare providers, and internal stakeholders regarding documentation requirements, missing information, processing status, and other service-related questions.
  • Escalation management: Identify complex or ambiguous cases and escalate them appropriately to the Member Services Processing Supervisor for guidance and resolution.
  • Privacy and compliance: Protect sensitive information by adhering to HIPAA requirements, privacy policies, and procedures governing personally identifiable and protected health information.
  • Quality assurance: Identify processing errors, recurring trends, and opportunities for improvement, sharing observations and recommendations with leadership.
  • Cross-training: Participate in training and process updates to provide effective support across enrollment, record maintenance, appeals routing, member correspondence, and related workflows.
  • Continuous improvement: Contribute ideas and feedback regarding workflow challenges, system issues, process inefficiencies, and potential operational enhancements.

  Requirements

  • Education: High school diploma or equivalent required.
  • Experience: 1–3 years of experience in processing, administrative support, data entry, customer service, healthcare operations, or a related operational environment.
  • Documentation skills: Strong attention to detail and demonstrated ability to review and analyze documentation against established requirements.
  • Communication: Strong written and verbal communication skills, with the ability to interact professionally with members, providers, colleagues, and other stakeholders.
  • Process discipline: Ability to follow detailed procedures accurately, maintain consistent documentation, meet deadlines, and operate within established compliance requirements.
  • Problem-solving: Strong customer problem-solving skills and sound judgment when identifying discrepancies, missing information, or cases requiring escalation.
  • Organization: Ability to multitask effectively, manage changing priorities, and maintain accuracy in a high-volume processing environment.
  • Technology: Comfortable using Microsoft applications and digital systems for documentation, data entry, case processing, and communication.
  • Adaptability: Demonstrated learning agility and willingness to participate in cross-training and adopt updated processes and technologies.
  • Preferred experience: Experience supporting federal health programs or healthcare operations is advantageous.
  • Preferred technology: Familiarity with intelligent document processing tools, member service portals, or platforms such as ServiceNow or CXone is a plus.
  • Work arrangement: Fully remote, with a standard 40-hour work week and limited travel of less than 10%.
  • Clearance: The role requires the ability to obtain and maintain a Public Trust designation.

  Benefits

  • Compensation: Expected hourly rate of $19.55–$26.45, with actual compensation based on experience, geographic location, and applicable contractual requirements.
  • Remote flexibility: Fully remote work with a full-flex work week designed to support professional and personal priorities.
  • Healthcare: Multiple medical plan options, including options with Health Savings Accounts, plus dental and vision coverage.
  • Retirement: 401(k) plan with company matching and pre-tax and post-tax contribution options.
  • Paid time off: Vacation, sick, personal, and holiday leave. New employees typically receive 15 days of paid leave per calendar year plus 10 paid holidays, subject to eligibility and prorating.
  • Family leave: Paid parental leave and a paid family leave program providing up to 160 hours during a rolling 12-month period for eligible employees.
  • Insurance protection: Short- and long-term disability, life insurance, accidental death and dismemberment, personal accident, critical illness, and business travel and accident coverage.
  • Professional development: Paid education and certification opportunities to support continuous learning and career growth.
  • Career mobility: Access to internal career mobility resources designed to help employees develop and advance professionally.
  • Technology exposure: Opportunities to learn and work with modern technologies and tools supporting healthcare and mission-focused operations.