Position Purpose:

In accordance with the Mission and Guiding Behaviors; the Member Service Representative responds to all consumer inquiries received by phone, in person or in writing regarding product plan benefits, services, organizational determinations, reconsiderations, complaints and general inquiries in accordance with the rules and regulations of a Medicare Advantage plan and governing agencies. Implements retention strategies to maintain current membership and improve the quality of care and service. 

What You Will Do: 

• Complies with internal policies, Center for Medicare and Medicaid Services (CMS), Ohio Department of Insurance (ODI), NCQA and all applicable Federal regulations. 

• Develop a thorough understanding of the applicable rules and audit protocols that govern all aspects consumer service activities and demonstrated ability to pass audits of activities. 

• Engages with consumers to effectively meet or exceed individual and team service performance goals in a manner that is compliant with all Federal, State and governing requirements. 

• Meets or exceeds Federal service level requirements for a Medicare Managed Care call center monitored by CMS or their appointed representatives. 

• Receive, interpret and accurately respond to consumer inquiries, both verbally and in writing in ways that reflect a positive, compassionate and affirming manner while ensuring compliance with Federal regulations. 

• Outreach to members and providers to close gaps in care, create and maintain relationships and obtain accurate information. Must be able to articulate and achieve desired outcomes. 

• To discern the needs of consumers with commitment to providing the highest level of service possible with measurable outcomes. 

• Utilize interpreting services and accurately provide answers to consumers via foreign language interpreters to assist limited English speaking consumers. 

• Achieve and maintain a superior (5-STAR) CMS rating in member/consumer satisfaction. 

Minimum Qualifications: 

• Education: Minimum of high school education with some college level studies preferred. 

• Experience: Customer Service along with knowledge of governmental agencies and regulations, especially Medicare and the Centers for Medicare and Medicaid Services (CMS) desired. 

• Effective Communication Skills; consumer retention and strategic thinking. 

• Demonstrated knowledge and effective organizing multi-tasks, in a high volume, fast-paced team environment. 

Position Highlights and Benefits: 

• Mount Carmel Health System recognized by Forbes in 2025 as one of America’s Best State Employers. 

• Competitive compensation and benefits packages including medical, dental, and vision with coverage starting on day one. 

• Retirement savings account with employer match starting on day one.  

• Generous paid time off programs. 

• Employee recognition programs. 

• Tuition/professional development reimbursement starting on day one. 

• RN to BSN tuition 100% paid at Mount Carmel’s College of Nursing. 

• Relocation assistance (geographic and position restrictions apply).  

• Employee Referral Rewards program. 

• Mount Carmel offers DailyPay - if you’re hired as an eligible colleague, you’ll be able to see how much you’ve made every day and transfer your money any time before payday. You deserve to get paid every day! 

• Opportunity to join Diversity, Equity, and Inclusion Colleague Resource Groups. 

Ministry/Facility Information: 

Mount Carmel, a member of Trinity Health, has been a transforming healing presence in Central Ohio for over 135 years. Mount Carmel serves over 1.3 million patients each year at our five hospitals, free-standing emergency centers, outpatient facilities, surgery centers, urgent care centers, primary care and specialty care physician offices, community outreach sites and homes across the region. Mount Carmel College of Nursing offers one of Ohio's largest undergraduate, graduate, and doctor of nursing programs. If you’re seeking a rewarding career where your purpose, passion, and desire to make a difference come alive, we invite you to consider joining our team. Here, care is provided by all of us For All of You!