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Member Services Rep

A30

Basic Purpose

Positions in this job family are assigned responsibilities involving acting as a plan liaison to employers, employees and categories of former employees, dependents or survivors, by marketing and providing membership and benefit information to eligible jurisdictions concerning employer participation and counseling members or training coordinators on qualifications for membership.  Determines individual or group membership, guides the individual or group through enrollment and provides counseling on benefit processes for access to health, dental, life, disability, vision, IRS Section 125 or Medicare Supplement benefits including problem resolution on membership eligibility or plan benefits.

Typical Function

The functions  within this job family will vary by level, but may include the following:

  • Provides authoritative oral or written responses to inquiries from all sources on eligibility, enrollment, change and termination processes; insurance applications for retirement, vesting, survivor or COBRA continuation; premium reconciliation processes; plan benefits and issues; and service access for one or more insurance and benefit plans; makes oral presentations in group settings before members, insurance committees, public administrator and other authorities.
  • Determines eligibility for participation for individuals and employer groups; resolves problems on eligibility or plan benefits/claim issues for active, retired, vested, COBRA, disabled, survivor or Medicare Supplement member categories.
  • Audits agency records to ensure compliance with established procedures; reviews and verifies enrollment, transfer, change and termination documents.
  • Interprets or explains policies and procedures, including federal and state laws, and regulations, to prospective and participating members or authorities; contributes to policy changes as reflection of the federal or state legislation or regulation creating an impact to the plan or the membership.
  • Maintains records of contacts with all sources, including group marketing profiles, as management resources; reviews records; prepares and analyzes statistical data; advises supervisors of significant changes and deviations from standards.
  • Makes field visits to employer sites throughout the state for service to coordinators and members; performs insurance coordinator training at individual or group level, including all aspects of eligibility, enrollment and benefit processes, employee orientations and annual enrollments; presents insurance eligibility and benefits in pre-retirement sessions and to retired organization meetings.
  • Makes field visits to employers of eligible jurisdictions for marketing or plan presentations on benefits, eligibility, agency or plan policies and procedures; enrolls members and reconciles enrollment forms as well as presents or explains the flexible benefit plan and IRS regulations applicable to premium conversion and spending accounts; contributes to marketing plans and performs marketing assignments to increase the membership base in compliance with legislation regarding eligible employer jurisdictions and/or agency marketing goals.

Level Descriptors

The Member Service Representative job family consists of three levels which are distinguished by the level of expertise required to perform the duties assigned, technicalities of assignments and the responsibility for providing leadership to others in carrying out the purposes of the agency at varying levels of authority and accountability.

Level I:                                                   Code:  A30A                                         Salary Band:  H

Employees at this level are assigned responsibilities involving entry level duties in the interpretation, explanation and application of laws, rules, regulations or procedures related to eligibility participation, benefit claims for health, dental, disability, life or vision, authorized benefit plan coverage, complaints and the actions needed to resolve problems on these inquiries.  Responds to requests from any source for information concerning plan benefits or member eligibility as oral and written communication.  Duties are performed under close supervision in a training status.

Knowledge, Skills and Abilities required at this level include knowledge of state and federal laws and regulations pertaining to various types of health, dental, vision, life, disability, flexible benefits or federally mandated programs; of agency and industry policies, procedures and guidelines concerning insurance or insurance claims processing; of marketing techniques; guidelines and procedures for membership or benefits; of medical dental and insurance terminology; and of modern office procedures including computerized record keeping.   Ability is required to analyze situations and exercising good judgment in reaching decisions;  to communicate both orally and in writing;  to provide assistance in planning and implementing insurance programs; and to establish and maintain effective working relationships with others.

Education and Experience requirements at this level consist of two years experience in the insurance industry involving marketing, customer service or sales of health, dental or life insurance or eligibility determination; or an equivalent combination of education and experience, substituting thirty semester hours of college which include nine semester hours in business administration, marketing, or public administration for each year of the required experience.

Level II:                                  Code:  A30B                                         Salary Band:  J

This is the career level where employees are assigned responsibilities for performing a full range of professional level duties involving marketing, policy interpretation, determination of eligibility for member enrollment or insurance changes, retirement insurance application or counseling, and member service for problem resolution involving claims or eligibility for benefits.  Limited supervision, flexibility and independence are required to meet legislative and agency directives for marketing and member service goals.

Knowledge, Skills and Abilities required at this level include those identified in Level I plus knowledge of the rules and regulations of the State and Education Employees Group Insurance Board,  and public speaking methods for public presentations.   Ability is required to develop marketing plans and presentations; in discussing and coordinating pre-enrollment preparations, enrollment and post-enrollment procedures;  to contribute to the development of marketing and member materials and forms;  to coordinate and implementing marketing of one or more insurance and benefit plans and IRS regulations applicable to insurance products;  to determine premium conversion;  to maintain spending accounts; and to conduct annual enrollment meetings or retirement seminars and instruct or assist insurance coordinators in all aspects of member activity relating to the membership or access to benefits.

Education and Experience requirements at this level consist of those identified in Level I plus two years of additional qualifying experience.

Level III:                                 Code:  A30C                                         Salary Band:  K

This is the leadership level where employees are assigned responsibilities for supervising and evaluating membership services, providing direct supervision to member services staff providing assistance to plan participants, third party administrators, participating employers and various authorities on eligibility, participation guidelines and processes, benefit plan information or access and the rules, regulations or statutes governing the program.  Intervenes on individual or group issues involving eligibility or benefit problems and communicates the resolution verbally or in writing.  Reviews member or plan material for proper application of member information on eligibility for membership or benefits.  Responsible for staff evaluations, disciplinary actions, provide staff development training as required, approve leave requests, and recommend changes in agency policies and procedures as appropriate.  Review and compile monthly reports on unit activities for management.

Knowledge, Skills and Abilities required at this level include those identified in Level II plus knowledge of current supervisory principles and practices.   Ability is required to develop and provide a comprehensive training and development program to staff members on marketing, rules, regulations, federal or state laws, agency or insurance policies, procedures and their application.

Education and Experience requirements at this level consist of those identified in Level II and two years of experience in the health, dental or life insurance industry involving membership determination, marketing, sales or service; or an equivalent combination of education and experience.

Special Requirements

Applicants must be willing and able to perform all job related travel normally associated with this position.