Member Service Advocate

Who We Are

Point
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Health is a leading not-for-profit health and well‑being organization dedicated to delivering high‑quality, affordable healthcare. Serving nearly 2million members, we build on the legacy of Harvard Pilgrim Health Care and Tufts Health Plan to provide access to care and empower healthier lives for everyone. Our culture revolves around being a community of care and shared values that guide our behaviors and decisions, with a long‑standing commitment to inclusion and equal healthcare access regardless of background.

Under the general direction of the Service Center Supervisor, the Member Services Advocate provides exceptional customer service, navigating the complexities of the healthcare system, dressing inquiries, resolving issues and ensuring members have a positive experience with Point
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Health. The Advocate is a member champion who resolves issues internally across a wide variety of departments and interacts externally with providers, employers, brokers and provider billing offices. A candidate should be proficient in working in multiple systems at once while doing real‑time analysis of data and documentation to resolve member inquiries.

Inbound Call Management – Handle inbound calls from members with professionalism and attentiveness, addressing inquiries related to health insurance benefits, coverage, claims and eligibility.

Health Care System Navigation – Support and advocate for members to ensure that they receive the care and support needed.

Problem Resolution – Provide education and guidance to members about their Point
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Health benefits and take ownership of each call to ensure that issues are resolved promptly and accurately. Follow up with members as needed to ensure complete resolution.

Member Engagement – Assist members in understanding and accessing their benefits and educate members on how to use self‑service tools, delivering proactive/anticipatory service.

Documentation and Reporting – Record call details and member interactions in the system accurately, ensuring that all relevant information is documented for future reference and reporting while complying with HIPAA, state and federal regulations and confidentiality standards.

Team Collaboration – Work collaboratively with other team members and departments to address complex issues and ensure a seamless member experience.

Member Experience – As a brand ambassador, go above and beyond to ensure member satisfaction, proactively identifying and addressing needs and concerns.

Continuous Improvement – Represent the voice of the customer by contributing to continuous improvement initiatives and providing feedback on member interactions and suggesting process enhancements.

Metrics & Goals – Adhere to assigned schedules to ensure appropriate phone queue coverage and meet or exceed department‑established key performance indicators.

Member Retention & Outbound Campaigns – Execute outbound calls to improve the member experience and assist in member retention.

Compliance and Policy Adherence – Ensure all interactions are HIPAA compliant and adhere to state and federal regulations.

Other duties as assigned.

Education, Certification and Licensure

• Required:
  
  Associate degree or equivalent work experience.
• Preferred:
  Bachelor’s degree or equivalent work experience.

Experience

• 0‑2 years of relevant experience.
• Preferred:
  Customer service experience in health care, call center or corporate office.
• Knowledge of medical terminology.
• Prior experience training and working in a virtual/remote setting.

Skill Requirements

• Customer Service Expertise – Demonstrated ability to provide exceptional service, including active listening, empathy, and clear communication with members.
• Empathy – Ability to put yourself in someone else’s shoes and demonstrate compassion.
• Product Knowledge – Strong understanding of health insurance products, policies, and industry regulations, or the ability to quickly learn and apply new information.
• Problem‑Solving/Critical Thinking – Adept at identifying issues, analyzing information, and providing effective solutions in a timely manner.
• Communication Skills – Excellent verbal and written…