Supervisor Provider and Member Service

Welcome! We’re excited you’re considering an opportunity with us! To apply to this position and be considered, click the Apply button located above this message and complete the application in full. Below, you’ll find other important information about this position.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. High school diploma or equivalent AND Three (3) years of experience working in a customer service call center environment AND Four (4) years of experience working in Commercial/ACA, CMS, Medicare, healthcare compliance, health plan operations, member services, or related environments.

OR

2. Associate’s degree AND Two (2) years of experience working in a customer service call center environment AND Three (3) years working in Commercial/ACA, CMS, Medicare healthcare compliance, health plan operations, member services, or related environment.

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor’s degree in healthcare administration, business administration, management, communications, or a related field.

2. Specialized courses, training, or seminars directly related to Commercial/ACA, CMS regulations, managed care, healthcare compliance, call center operations, leadership, or business management.

EXPERIENCE:

1. Two (2) years of experience in a healthcare, health insurance, or managed care.

2. Two (2) years of experience in a team lead or direct supervisory role overseeing customer service or call center associates.

3. Experience supervising employees in a regulated healthcare, health insurance, Commercial/ACA, CMS, or managed care environment.

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position. They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1. Oversees daily department operations, ensuring team members consistently follow established policies, procedures, and service standards while maintaining operational efficiency and compliance.

2. Monitor live and recorded member and provider interactions, evaluate individual and team performance metrics, and partner with Team Leads to deliver timely coaching, actionable feedback, and development plans that drive service excellence, quality outcomes, compliance, and achievement of departmental goals.

3. Member and Provider Escalations: Handle complex or escalated inquiries from plan members regarding benefits, claims, or eligibility, and resolve difficult issues for healthcare providers regarding claims, referrals, and reimbursement structures.

4. Ensures departmental operations and member interactions comply with CMS requirements, Commercial ACA, Medicare regulations, Medicaid requirements, HIPAA, organizational policies, compliance standards, and applicable state and federal regulations.

5. Oversees the use of SharePoint and other approved systems to manage team resources and departmental documentation, including updating shared sites, maintaining current policies and procedures, managing access, and ensuring staff can locate required training and reference materials.

6. Demonstrates flexibility in meeting departmental and organizational needs related to changes in call volume, staffing, scheduling, business operations, regulatory requirements, system issues, emergencies, and special outreach initiatives.

7. Identifies on-going continuing education needs of existing employees as well as new employees.

8. Complete annual reviews as well as 90-day review.

9. Keeps staff informed of process, policy and other changes through presentation at regular staff meetings, face to face communication and email correspondence.

10. Participate in meetings with other Peak Health departments to stay current on actions affecting Customer Service and Insurance workflows.

11. Organizes and executes daily tasks in appropriate priority to achieve optimal productivity, accountability, and efficiency.

12. Demonstrates an understanding of healthcare and health plan operations, including eligibility, enrollment, claims, benefits, provider networks, pharmacy coverage, authorizations, billing, grievances, appeals, and reimbursement-related matters.

13. Works with manager to develop and attain quarterly objectives.

14. Demonstrated confidentiality and discretion when interacting with members or about members in compliance with HIPAA and policies and standard set forth by Peak.

15. Demonstrates flexibility to meet the needs of the department or hospital in regard to changes in work volume, planned change, scheduling changes, and emergency call – backs (i.e. weather or disaster).

16. Partners with Quality, Training, and Compliance teams to develop and deliver training, reinforce performance expectations, and address identified knowledge or process gaps. Supports employee onboarding, system access, training, mentoring, and transition to independent call handling

17. Promotes a professional, collaborative, inclusive, and accountable work environment focused on member experience, regulatory compliance, continuous improvement, and operational excellence.

18. Participates in the recruitment, interviewing, selection, onboarding, and retention of qualified Member Services representatives.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Ability to sit, stand, walk, and use standard office equipment for extended periods of time.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Exposed to high stress and constant interruptions.

2. Standard office environment.

SKILLS AND ABILITIES:

1. Excellent verbal and written communication skills, including the ability to communicate complex healthcare, Medicare, and regulatory information clearly and professionally.

2. Knowledge of medical terminology.

3. Ability to monitor and interpret call center performance metrics, quality results, productivity measures, and service-level data to identify trends and opportunities for improvement.

4. Excellent Customer Service and telephone etiquette.

5. Strong decision-making, problem-solving, critical-thinking, and analytical skills, with the ability to assess complex situations and determine appropriate actions.

Additional Job Description:

Scheduled Weekly Hours:

Shift:

Exempt/Non-Exempt:

Company:

Cost Center:

Welcome

Thank you for your interest in working for WVUM. Please explore our open opportunities in the list below and apply for any positions in which you would like to be considered. You'll be able to keep track of your progress on our site.

About the WVU Health System

The West Virginia University Health System is a West Virginia-based academic health system that provides the full continuum of healthcare services at 30 hospitals in West Virginia, Pennsylvania, Ohio, and Maryland. With more than 47,000 employees, of which 7,200 are providers, and $10 billion in total operating revenues, the WVU Health System is anchored by an 890-bed academic medical center and the 150-bed WVU Medicine Golisano Children’s Hospital in Morgantown, West Virginia. Together, the Health System’s hospitals, clinics, and specialty programs provide a comprehensive continuum of care, ranging from community-based primary and specialty services to highly complex, quaternary care and post-acute care.