Member Services Processing Specialist

Supports day-to-day operations within a third-party administrator healthcare environment by reviewing, validating, and processing member applications, certifications, transfers, appeals, designated representative appointments, documentation, and service requests.

This role helps ensure members experience a smooth and efficient program experience while maintaining accuracy, compliance, and service quality across all processing activities. The specialist works closely with supervisors and cross-functional teams, using member services systems and tools to support timely and compliant workflow execution.

Responsibilities

• Process enrollment applications, documentation, certifications, transfers, appeals, and designated representative appointments and updates in accordance with program policies, SOPs, and federal requirements.
• Review member-submitted materials for completeness, accuracy, and eligibility.
• Analyze documentation to determine whether submissions meet program enrollment requirements.
• Perform data entry and record updates within member services tools, including digital mail center systems, entry portals, and intelligent document processing platforms.
• Maintain accurate case notes, documentation, and processing records for program review, compliance, and audit readiness.
• Communicate professionally with members, providers, and internal stakeholders regarding documentation requirements, missing information, or status updates.
• Escalate complex or ambiguous cases to the Member Services Processing Supervisor.
• Adhere to HIPAA and program privacy requirements when handling PII/PHI.
• Support quality assurance activities by identifying errors, trends, and process improvement opportunities.
• Participate in cross-training and process updates across enrollment, record updates, appeals routing, and member correspondence.
• Contribute to continuous improvement efforts by providing feedback on workflow challenges, system issues, and enhancement opportunities.