Member Services Processing Specialist

The Member Services Processing Specialist supports day‑to‑day operations within a Third‑Party Administrator (TPA) healthcare environment by reviewing, validating, and processing member applications, certifications, transfers, appeals, designated representative appointments, documentation, and service requests. The specialist ensures an efficient and positive program experience for members while maintaining accuracy, compliance, and service quality across all processing activities.

Key Responsibilities

• Own end‑to‑end processing of enrollment applications, certifications, transfers, appeals, designated representative appointments, and member record updates in accordance with program policies, SOPs, and applicable federal requirements.
• Perform detailed reviews of member‑submitted materials to validate completeness, accuracy, and eligibility; determine required follow‑up actions and coordinate with members, providers, and internal stakeholders.
• Exercise independent judgment to evaluate documentation against program enrollment and certification criteria; identify edge cases and recommend resolution paths.
• Use member services tools (digital mail center systems, intake/entry portals, intelligent document processing platforms) to triage, route, and process documentation, ensuring service‑level adherence.
• Maintain high‑quality case notes and processing records to support program audits, compliance reviews, and operational analytics.
• Partner with supervisors and cross‑functional teams (member services, clinical policy, provider services, call center, data/reporting) to resolve complex scenarios and improve workflow efficiency.
• Monitor operational metrics (e.g., backlog, turnaround time, accuracy rate) and contribute to corrective actions and continuous improvement initiatives.
• Handle PII/PHI in accordance with HIPAA and program privacy requirements; follow security and access controls.
• Escalate ambiguous or high‑risk cases with clear documentation and decision rationale; support quality assurance by identifying trends and error drivers.
• Participate in cross‑training to provide surge coverage across enrollment, record updates, appeals routing, designated representative processing, and member correspondence.

Decision Rights and Scope

• Applies established policies and SOPs with discretion; identifies exceptions and proposes resolution options to leadership.
• Prioritizes work using risk‑based criteria and service levels; determines appropriate sequencing and follow��up actions.
• Recommends process improvements and contributes to SOP updates; participates in validation/testing when new procedures or tools are introduced.

Required Qualifications

• High School Diploma or equivalent.
• 1–3 years of experience in processing, administrative support, data entry, customer service, or related operations.
• Strong written and verbal communication skills.
• Ability to follow detailed procedures, meet deadlines, and adapt to changing priorities.
• Demonstrated analytical skills with close attention to detail; capable of evaluating documentation against defined program requirements.

Preferred Qualifications

• Background supporting federal health programs or healthcare operations.
• Experience with intelligent document processing tools, member service portals, or customer support platforms (e.g., ServiceNow, CXone).
• Exposure to HIPAA‑regulated environments and familiarity with handling PII/PHI.

Core Competencies

• Accuracy and Quality
• Service Orientation
• Problem Solving
• Accountability
• Process Discipline
• Adaptability and Learning Agility
• Team Collaboration

• Full-flex work week to own your priorities at work and at home.
• 401K with company match.
• Comprehensive health and wellness packages.
• Internal mobility team dedicated to helping you own your career.
• Professional growth opportunities including paid education and certifications.
• Cutting-edge technology you can learn from.
• Rest and recharge with paid vacation and holidays.