Member Benefits Advocate - Fairos

Job Summary:  As a Member Benefits Advocate, you will serve at the forefront of The OccuNet Company’s experience-centric approach, improving the health and well-being of members.  You will utilize your interpersonal abilities to provide members with exceptional support by delivering high-quality, professional, and efficient service across multiple channels.  You will also liaise with members and providers to resolve inquiries to assist in the navigation of Reference-Based Pricing (RBP) health plans.

What it’s Like to Work Here:  At OccuNet, you matter like we matter!  Our team members share a positive attitude, an outward mindset, problem-solving abilities, and patience, enabling them to provide excellent customer service even during challenging situations. Our culture, plus continuous opportunities for growth, has resulted in an industry-low turnover rate. Don’t miss out on this rare opening with us!

A Day in the Life: The Member Benefits Advocate is responsible for all inbound phone, chat, and email intake for the Fairos+ line of business. This communication comes from both health plan members and providers and can include, but is not limited to, quotation of benefits, eligibility inquiries, claim status, balance billing situations, member plan education, member physician or facility access issues, and other claim-related billing questions. Member Benefits Advocates are responsible for providing members and providers with requested information in a clear, timely, and professional manner. The team member is responsible for making outbound calls to providers, clients, and TPA partners to gather appropriate information or submit requests as needed to reach a timely resolution. The Member Benefits Advocate will also attend various meetings and training sessions to ensure they are fully capable and up to date on job roles and responsibilities.

Duties & Responsibilities:

• Uphold best-in-class member experiences by owning the end-to-end resolution process, which includes thoughtfully guiding members throughout their healthcare journey.
• Practice TOC’s “outward mindset” philosophy through providing empathic support to members, remaining conscious of their unique situations and needs.
• Service members as they navigate their employer sponsored healthcare plans by quoting benefits, interpreting plan documents, answering questions regarding claim status and Explanation of Benefit (EOB) documents, and assisting in finding quality care providers.
• Service providers by providing eligibility verification, quoting benefits, and answering questions regarding claim status and pricing inquiries. Additionally, will work with providers on behalf of members to resolve payment-related inquiries.
• Proactively anticipate the needs of members and offer solutions that support and enhance the member experience.
• Work across cross-functional teams, including Account Management and Contracting, to establish processes that relieve any challenges members are facing.
• Uphold compliance and confidentiality standards relating to HIPAA and Department of Labor guidelines when corresponding with members or providers and maintaining documentation.
• Perform other duties as assigned.

Required Skills and Abilities:

• High school diploma or equivalent required.
• Bilingual verbal and written fluency in English and Spanish preferred.
• 2+ years of customer service experience in member services, health care, or in a customer service or call center environment required.
• 1+ years of experience directly interpreting and explaining medical, dental, and/or vision plan benefits to both plan members and healthcare providers required.
• Strong understanding of benefit interpretation, including coverage and eligibility, member cost-share, plan limitations/exclusions, and prior authorization requirements.
• For remote candidates, ability to maintain a private, distraction-free workspace with a reliable high-speed internet connection suitable for handling confidential member information and phone-based work.
• Team-first mindset with a high level of motivation and drive.
• Naturally compassionate with an ability to navigate sensitive and challenging situations with care, patience, and professionalism.
• Passionate and proactive in contributing to organizational missions focused on improving member healthcare experiences.
• Persistent, detail oriented, and committed to seeing tasks through to completion with a high degree of accuracy.