Member and Provider Services Specialist

Skip to Main Content CareersLog inMember and Provider Services SpecialistShow All JobsApplyLocationRemote - TX, United StatesJob CategoryContact Center, Member ServicesIndustryHealthcareEmployee TypeNon-Exempt - FTMinimum Experience2 YearsContact informationNameAbby HelselPhone512-766-1346Emailabby.hallman@harborhealth.comDescriptionHarbor HealthMember & Provider Services SpecialistTexas Markets  |  Member & Provider Services  |  Full-Time POSITION OVERVIEWHarbor Health is seeking a compassionate, highly skilled, and solution-oriented Member & Provider Services Specialist to join our innovative, integrated healthcare organization. As a key ambassador of the Harbor Health experience, you will serve as a trusted resource for members, providers, and business partners by delivering exceptional service across both our health plan and medical group. You will support a broad spectrum of member and provider inquiries throughout the healthcare journey — including educating members on benefits and coverage, resolving claims and billing questions, supporting enrollment and eligibility, assisting with referrals and prior authorizations, and managing complaints, grievances, and appeals in accordance with regulatory requirements. This role is central to delivering Harbor Health's commitment to a unified, frictionless, member-centered experience that aligns with our mission of transforming healthcare through our payvider model. POSITION DUTIES & RESPONSIBILITIESMember ServicesServe as the primary point of contact for members through phone, email, chat, and other communication channelsEducate members regarding health plan benefits, eligibility, covered services, exclusions, deductibles, copays, coinsurance, and out-of-pocket responsibilitiesAssist members with provider selection, appointment scheduling, referrals, and navigation throughout the healthcare systemGuide members through enrollment, eligibility updates, PCP changes, and Marketplace or Large Group insurance questionsAssist members with portal registration and digital self-service toolsPromote first-call resolution while delivering a personalized, empathetic member experienceProvider ServicesServe as a primary resource for participating and non-participating providersSupport provider inquiries regarding member eligibility, benefits, claim status, payment, referrals, prior authorizations, and network participationEducate providers on Provider Relations and Network Management processes to resolve provider concerns efficientlyEligibility & BenefitsVerify member eligibility and benefits using Athena, payer portals, and internal systemsConfirm benefit coverage, network participation, plan limitations (HMO, PPO, POS, Marketplace, etc.), and applicable member financial responsibilityEducate members regarding referral requirements and available in-network resources to improve access and reduce out-of-pocket costsResolve eligibility discrepancies by working directly with health plans or guiding members through corrective actionsClaims & Billing SupportResearch and resolve claims inquiries for members and providersExplain claim adjudication, payment determinations, denials, coordination of benefits, and reimbursement processesAssist with billing questions, patient balances, payment options, and payment plan informationEscalate complex financial or reimbursement issues to Claims or Billing teams while maintaining ownership of the member experiencePrior Authorization & ReferralsEducate members and providers regarding prior authorization requirements, referral processes, and documentation needsExplain authorization status, next steps, and expected turnaround timesCoordinate with Utilization Management and Clinical Operations to facilitate timely resolutionAppeals, Grievances & ComplaintsIntake and document member and provider complaints, grievances, and appeals accurately and completelyEnsure all required documentation is collected to support investigations and regulatory reviewMaintain...