Care Concierge – Member Support Specialist

Role Overview

• Responds to inbound calls from health plans, employer groups, employees, and family members within 30 seconds, delivering exceptional, professional support in a timely, courteous, and energetic manner to members planning an elective surgical or medical procedures.
• Accurately documents and communicates consumer interactions, including handling inbound calls, emails, and chats, as well as conducting outbound follow-up calls and responding promptly to emails and voicemails.
• Promotes SmartShopper products and services, encouraging consumer engagement with Zelis offerings and supporting adoption of new program initiatives.
• Researches, analyzes, and escalates member incentive inquiries to the appropriate internal team, clearly communicating resolution steps and updates to consumers.
• Leverages internal databases to generate reports on claim history, procedure code matching, accounts on hold, incentive check fulfillment status, claim load schedules, shopping confirmation codes, exception payments, and consumer search history.
• Communicates with consumers’ health insurance carriers to obtain, validate, and confirm accurate claim status and program eligibility information.
• Contacts members’ sites of service, as needed, to verify the status of insurance claims.
• Monitors, documents, and maintains accurate records for all related inquiry cases, ensuring proper case assignment and timely resolution by the appropriate individual or team.
• Supports digital and direct mail engagement campaigns by interacting with consumers to confirm registration and encourage active participation in SmartShopper program offerings.
• Partners regularly with the SmartShopper Staff Development and Quality Management (QM) Specialist to fulfill ongoing education and training requirements, including completing refresher courses and knowledge checks within designated timeframes.
• Collaborates with the SmartShopper Staff Development and QM Specialist to meet or exceed QM scorecard targets and maintain high consumer satisfaction ratings in alignment with Zelis and Customer Care standards.
• Works closely with the Finance team to verify reward check status and ensure proper documentation and voiding when reissuing incentive payments is necessary.
• Applies analytical and problem-solving skills to identify, document, and escalate trends related to member inquiries, complaints, unpaid incentives, and other departmental performance improvement opportunities to leadership.
• Communicates with members’ sites of service to research and document billing discrepancies as they arise.
• Collaborates with the Data team to support the processing and distribution of reward incentive checks.

Requirements

• Minimum of 1+ year of customer service experience required
• Healthcare experience required
• Experience supporting and navigating online consumer shopping tools is highly preferred
• Proficiency with CX1 and customer relationship management (CRM) systems, such as Salesforce, is strongly desired
• Familiar with using healthcare claims look-up and management systems is highly desired
• Associates degree preferred
• Familiar with using Microsoft Office applications e.g. Excel, Word, PowerPoint, Outlook, and Google Docs
• Excellent telephone-based customer service, including strong verbal communication and active listening skills required
• Strong healthcare literacy, with the ability to understand and interpret complex medical and surgical procedure information
• Analytical and independent problem-solving abilities, with strong multitasking skills and the capacity to prioritize and manage time effectively
• Customer-focused mindset with the ability to effectively engage individuals of diverse personalities, backgrounds, ethnicities, and age groups
• Knowledge of medical insurance claims processes and medical coding (e.g., CPT, DRGs) helpful
• Bilingual English/Spanish communication skills are highly preferred

Benefits

• 401k plan with employer match
• Flexible paid time off
• Holidays
• Parental leaves
• Life and disability insurance
• Health benefits including medical, dental, vision, and prescription drug coverage