Supervisor, Provider and Member Service

Job not on LinkedIn

🔥 3 minutes ago

🇺🇸 United States – Remote

⏰ Full Time

🟠 Senior

🔴 Lead

👻 Ghost score 10%

What it means: the chance that no one is really hiring for this job.How to read it: 60% or higher means we think this is a ghost. Lower scores are less of a worry.How we score it: age, reposts, open roles vs team size, how fast jobs close, and whether pay is listed.Fine print: an estimate from public data, not a judgment of the company. Real jobs can score high, so treat it as a hint, not a fact.

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Peak Health

WebsiteLinkedInAll Job Openings

51 - 200 employees

🏥 Healthcare

💼 Consulting

🛡️ Insurance

Healthcare • Consulting • Insurance

Peak Health is a health insurer and health insurance services company headquartered in Morgantown, West Virginia. It is owned by three not-for-profit health care providers: WVU Health System, Marshall Health Network, and Valley Health. Peak Health aims to improve community health outcomes by offering an inclusive, provider-led health plan for residents of West Virginia and surrounding areas. The company is committed to making health care more accessible, understandable, and collaborative, with a focus on reducing costs and administrative fees for patients and employers. Peak Health also offers Medicare Advantage coverage tailored for West Virginia seniors through partnerships with leading health systems.

📋 Description

• Oversee daily operations of the Member and Provider Services team, ensuring policies, procedures, service standards, efficiency, and compliance • Monitor live and recorded member and provider interactions and evaluate performance metrics • Provide coaching, actionable feedback, development plans, training, mentoring, and onboarding support • Handle complex or escalated member inquiries regarding benefits, claims, and eligibility • Resolve difficult provider issues involving claims, referrals, and reimbursement structures • Ensure operations and interactions comply with CMS, Commercial ACA, Medicare, Medicaid, HIPAA, organizational, state, and federal requirements • Oversee SharePoint and approved systems, departmental documentation, policies, procedures, access, and training materials • Adapt operations to call volume, staffing, scheduling, business, regulatory, system, emergency, and outreach needs • Identify continuing education needs and complete annual and 90-day reviews • Keep staff informed of process and policy changes through meetings, face-to-face communication, and email • Participate in cross-departmental meetings concerning Customer Service and Insurance workflows • Organize daily priorities to achieve productivity, accountability, and efficiency • Work with the manager to develop and attain quarterly objectives • Maintain confidentiality and discretion in compliance with HIPAA and Peak policies • Partner with Quality, Training, and Compliance teams to deliver training and address knowledge or process gaps • Promote a professional, collaborative, inclusive, accountable, and member-focused work environment • Participate in recruitment, interviewing, selection, onboarding, and retention of Member Services representatives

🎯 Requirements

• High school diploma or equivalent AND three (3) years of experience working in a customer service call center environment AND four (4) years of experience working in Commercial/ACA, CMS, Medicare, healthcare compliance, health plan operations, member services, or related environments; OR associate’s degree AND two (2) years of customer service call center experience AND three (3) years of experience in Commercial/ACA, CMS, Medicare healthcare compliance, health plan operations, member services, or related environments • Preferred: Bachelor’s degree in healthcare administration, business administration, management, communications, or a related field • Preferred: specialized courses, training, or seminars related to Commercial/ACA, CMS regulations, managed care, healthcare compliance, call center operations, leadership, or business management • Preferred: two (2) years of experience in healthcare, health insurance, or managed care • Preferred: two (2) years of experience in a team lead or direct supervisory role overseeing customer service or call center associates • Preferred experience supervising employees in a regulated healthcare, health insurance, Commercial/ACA, CMS, or managed care environment • Availability Monday through Friday, 8:00 a.m. to 5:00 p.m. during call center operations • Knowledge of CMS requirements, Commercial ACA, Medicare, Medicaid, HIPAA, and applicable state and federal regulations • Understanding of healthcare and health plan operations, including eligibility, enrollment, claims, benefits, provider networks, pharmacy coverage, authorizations, billing, grievances, appeals, and reimbursement • Excellent verbal and written communication skills, including ability to communicate complex healthcare, Medicare, and regulatory information clearly and professionally • Knowledge of medical terminology • Ability to monitor and interpret call center performance metrics, quality results, productivity measures, and service-level data • Excellent customer service and telephone etiquette • Strong decision-making, problem-solving, critical-thinking, and analytical skills • Ability to sit, stand, walk, and use standard office equipment for extended periods

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