The Senior Member Advocate is a vital role in ensuring service excellence to Zelis clients and their members. The Senior Member Advocate is proficient in and supports all Preservice Outreach, Balance Bill Resolution, and No Surprises Act assignment categories. This position requires the ability to act independently within the scope of assigned duties and responsibilities and within established policies and guidelines, the ability to effectively multitask, and to consistently meet or exceed performance standards. The Senior Member Advocate is a subject matter expert for the team. All job functions will be completed using approved policies and procedures, and system design and technical documentation for all Zelis systems and product offerings.

Preservice Outreach Assignments

• Independently determine appropriate action to resolve inquiries and questions regarding provider outreach requests, provider status, and open case status.

• Respond to inbound calls and self-service request from Plan members, providers, and clients.

• Educate members and providers on health plan and plan payment methodology.

• Negotiate with providers to secure acceptance of health plan reimbursement payment methodology within parameters, guidelines, and protocols set forth by the Health Plan when requested while maintaining professionalism and diplomacy.

• Comply with HIPAA regulations and ensure confidentiality of calls, documents, and other sensitive information.

• Assist in facilitation of Memorandum of Understandings (MOU) or Single Case Agreements (SCA) as required.

• Generates correspondence when required, ensuring that correspondence is free of grammatical and spelling errors.

• Maintain composure and diplomacy during all client, member, and provider interactions.

• Properly document activity and calls in the appropriate Zelis system(s).

• Update provider database to maintain an accurate listing of provider status, including providers’ acceptance or rejection of the health plan’s payment methodology.

Balance Bill Resolution Assignments

• Research and respond to calls, respond to email, fax, or self-service submissions inquiries from Health Plan members, clients, and providers regarding balance bills.

• Acts independently to determine appropriate actions to resolve inquiries and balance billing tasks within established service level indicators in adherence to policies, procedures, protocol, and workflow.

• Educate members and providers on Health Plan and Plan payment methodology and member liability.

• Generate appropriate correspondence and follow-up correspondence as needed ensuring it is free of spelling and grammatical errors.

• Comply with HIPAA regulations and ensure confidentiality of calls, documents, and other sensitive information.

• Properly document activity and calls in the appropriate Zelis system(s).

• Escalate balance bill events as appropriate and guided by established policy.

• Assist Plan members with filling credit bureau disputes.

• Assist members with assist members with review of their Explanation of Benefits and calculation of deductible, out-ot-pocket, co-payments, and patient liability.

No Surprises Act Support Assignments

• Assist client with facilitation of Open Negotiations as mandated by CMS guidelines and established policy.

• Communicate with provider and client through email, phone, fax, or US mail ensuring all communication is free of grammatical error. This includes offers, counteroffers, offer and release documents, etc.

• Comply with HIPAA regulations and ensure confidentiality of calls, documents, and other sensitive information.

• Generate the Qualified Payment Amount (QPA) for the claims in Negotiations.

• Upon direction and within parameters established by the Plan, the advocate will work to secure a settlement with the provider.

• If no settlement is reached and the case results in an Independent Dispute Resolution, the Senior Member Advocate will assist the Plan in their response by providing a summary of all offers and counteroffers, access to all correspondence and communications, claim process trail and QPA, redacted documents, and data point analysis as requested.

Other Duties as Assigned

• Special projects as assigned by the leadership team.

• Miscellaneous office duties as assigned.

• Back-up to other positions as assigned by the leadership team.

Qualification and Education Requirements

• High School Diploma/GED required; Associate degree preferred.

• Minimum of three years working in a call center, billing/accounts receivable in a hospital or doctor’s office setting, or healthcare claims adjudication, within a production environment within the healthcare/managed care industry.

• Familiar with various reimbursement methodologies, benefit calculations, and Medicare reimbursement.

• Proficiency in basic computer skills, system applications, databases, etc.

• Understands healthcare insurance principles, products, and concepts.

• Excellent communication skills, both verbal and written.

• Excellent attention to detail, time management and decision-making skills.

• Excellent customer service skills with the ability to maintain professionalism, decorum, tack, and diplomacy even during tense situations.

• Proficient in computer usage.

• Experience with MS Office products.

• Ability to use standard office equipment, faxes, copiers, etc.

Physical Demand

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Fingering: Picking, pinching, typing or otherwise working primarily with fingers rather than with whole hand or arm, as in handling.

Speaking: Expressing or exchanging ideas by means of spoken word. Those activities in which require detailed or important spoken instructions must be conveyed to other workers accurately and quickly.

Hearing: Ability to receive detailed information through oral communication with or without correction.

Repetitive Motion: Substantial movement (motions) of the wrist, hands, and fingers.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Normal office environment with controlled temperature. The noise level in the work environment is usually moderate.

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As a leading payments company in healthcare, we guide, price, explain, and pay for care on behalf of insurers and their members. We’re Zelis in our pursuit to align the interests of payers, providers, and consumers to deliver a better financial experience and more affordable, transparent care for all. We partner with more than 700 payers, including the top-5 national health plans, BCBS insurers, regional health plans, TPAs and self-insured employers, over 4 million providers, and 100 million members, enabling the healthcare industry to pay for care, with care. Zelis brings adaptive technology, a deeply ingrained service culture, and a comprehensive navigation through adjudication and payment platform to manage the complete payment process.

Commitment to Diversity, Equity, Inclusion, and Belonging
At Zelis, we champion diversity, equity, inclusion, and belonging in all aspects of our operations. We embrace the power of diversity and create an environment where people can bring their authentic and best selves to work. We know that a sense of belonging is key not only to your success at Zelis, but also to your ability to bring your best each day.

Equal Employment Opportunity
Zelis is proud to be an equal opportunity employer. All applicants will receive consideration for employment without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws.

We encourage members of traditionally underrepresented communities to apply, even if you do not believe you 100% fit the qualifications of the position, including women, LGBTQIA people, people of color, and people with disabilities.

Accessibility Support

We are dedicated to ensuring our application process is accessible to all candidates. If you are a qualified individual with a disability or a disabled veteran and require a reasonable accommodation with any part of the application and/or interview process, please email TalentAcquisition@zelis.com

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