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Claims Management - Member Service Representative

St. Louis, MO, USA Req #89
Thursday, April 30, 2020


Peak TPA is a third party administrator (TPA) that provides back-office functions for capitated health plans. Back-office functions include but are not limited to claims adjudication, member enrollment and reporting, and financial reporting. Peak TPA's partner company, Mediture/Cognify, has a long history in providing software solutions for managing care coordination for capitated health plans. Both companies (subsidiaries of Tabula Rasa Healthcare Company) work closely together to provide integrated and intuitive products to our health plans.

Peak TPA's goal is to seamlessly handle our client’s back-office functions to allow the plan to financially thrive and grow so they can focus on member care coordination.






Job Description:             Member Service Representative


Summary: Under the supervision of the Director of Client and Provider Relations, the Member Service Representative is responsible for answering calls from our clients’ enrolled members and providing timely and accurate responses in a professional and courteous manner. This position also assists with various internal tasks that ensure a high level of overall client satisfaction.

Essential Functions:

  • Responds to member phone inquiries in a timely manner; provides accurate responses in a professional and courteous manner

  • Researches inquiries using appropriate team members as a resource

  • Follows up as needed to relay claim status or obtain further information

  • Assists team with providing claim status for client inquiries

  • Ensures that HIPAA guidelines are followed in every communication with providers, clients or staff

Additional Functions:

  • Assists with special projects, as requested

  • Communicates clearly and concisely, with sensitivity to the needs of others

  • Maintains the confidentiality of all company procedures, results, and information about participants, clients, providers and employees

  • Maintains courteous, helpful and professional behavior on the job; displays a willingness and ability to be responsive in a warm and caring manner to all customer groups. Consistently cooperates and supports organization in problem solving issues.

  • Establishes and maintains effective working relationships with co-workers

  • Follows all Policies and Procedures and HIPAA regulations

  • Participates in any recommended or required training sessions

  • Maintains a safe working environment


Supervisory Responsibility: None

Travel: Minimal travel, less than 10%, expected for this position

Knowledge, Skills and Abilities:

  • Educational requirements include a High School Diploma or equivalent. One year of professional work experience required, preferably in a health plan setting.

  • Previous call center experience preferred

  • General knowledge of medical terminology preferred

  • Knowledge and experience using current computer technology, and a strong knowledge of Excel and Word.

  • Skilled in establishing and maintaining effective working relationships with clients, and staff at all levels

  • Skilled in problem resolution; recommends suggestions to increase accuracy and/or efficiency

  • Ability to have superior attendance to fulfill all position functions

  • Ability to work independently with minimal supervision

  • Ability to communicate professionally, clearly and effectively, verbally and in writing

  • Ability to prioritize effectively

  • Ability to multitask


Physical Demands & Requirements:

  • Communicates by way of the telephone with providers, participants, customers, and vendors; majority of the work day is spent communicating on the telephone

  • Operates a computer and other office productivity machinery, such as a calculator, copy machine, fax machine and office printer

  • Remains stationary for extended periods of time

  • Occasionally exerts up to 20 pounds of force to lift, carry, push, pull or move objects

  • Visual acuity to perform activities such as identifying, inputting and analyzing data on a computer terminal and/or in hard copy

  • Occasional reaching to retrieve shelved items

  • Occasional bending/stooping


Work Environment:

  • This job operates in a professional/home office environment with a conversational noise level.

  • No substantial exposure to adverse environmental conditions is expected.

  • Moderate pressure to meet scheduled appointments and deadlines

  • Moderate potential for occasional verbal aggression by providers and clients

Other details

  • Job Function Management
  • Pay Type Hourly
  • Industry Other
  • Telecommute % 100
  • Required Education High School
  • St. Louis, MO, USA