Harbor Health
Member & Provider Services Specialist
Texas Markets | Member & Provider Services | Full-Time
POSITION OVERVIEW
Harbor 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 & RESPONSIBILITIES
Member Services
Serve as the primary point of contact for members through phone, email, chat, and other communication channels
Educate members regarding health plan benefits, eligibility, covered services, exclusions, deductibles, copays, coinsurance, and out-of-pocket responsibilities
Assist members with provider selection, appointment scheduling, referrals, and navigation throughout the healthcare system
Guide members through enrollment, eligibility updates, PCP changes, and Marketplace or Large Group insurance questions
Assist members with portal registration and digital self-service tools
Promote first-call resolution while delivering a personalized, empathetic member experience
Provider Services
Serve as a primary resource for participating and non-participating providers
Support provider inquiries regarding member eligibility, benefits, claim status, payment, referrals, prior authorizations, and network participation
Educate providers on Provider Relations and Network Management processes to resolve provider concerns efficiently
Eligibility & Benefits
Verify member eligibility and benefits using Athena, payer portals, and internal systems
Confirm benefit coverage, network participation, plan limitations (HMO, PPO, POS, Marketplace, etc.), and applicable member financial responsibility
Educate members regarding referral requirements and available in-network resources to improve access and reduce out-of-pocket costs
Resolve eligibility discrepancies by working directly with health plans or guiding members through corrective actions
Claims & Billing Support
Research and resolve claims inquiries for members and providers
Explain claim adjudication, payment determinations, denials, coordination of benefits, and reimbursement processes
Assist with billing questions, patient balances, payment options, and payment plan information
Escalate complex financial or reimbursement issues to Claims or Billing teams while maintaining ownership of the member experience
Prior Authorization & Referrals
Educate members and providers regarding prior authorization requirements, referral processes, and documentation needs
Explain authorization status, next steps, and expected turnaround times
Coordinate with Utilization Management and Clinical Operations to facilitate timely resolution
Appeals, Grievances & Complaints
Intake and document member and provider complaints, grievances, and appeals accurately and completely
Ensure all required documentation is collected to support investigations and regulatory review
Maintain compliance with CMS, TDI, NCQA, HIPAA, and Harbor Health policies
Escalate potential compliance, quality of care, patient safety, or regulatory issues appropriately
Network Access & Care Navigation
Identify access-to-care concerns and potential network adequacy issues
Assist members in locating participating providers and obtaining timely appointments
Escalate network access barriers in accordance with regulatory access standards
Support members through complex care coordination and navigation needs
Documentation & Communication
Manage high-volume inbound and outbound phone calls, emails, and written correspondence
Accurately document all member and provider interactions in applicable systems
Maintain detailed case notes while ensuring confidentiality of Protected Health Information (PHI)
Follow approved communication standards while personalizing interactions to meet individual member needs
Operational Excellence
Meet established quality, productivity, attendance, and service level expectations
Demonstrate flexibility in a rapidly evolving healthcare environment
Participate in ongoing training, coaching, and professional development
Support continuous improvement initiatives designed to enhance the member and provider experience
DESIRED PROFESSIONAL SKILLS & EXPERIENCE
Required:
High School Diploma or equivalent; Associate's or Bachelor's degree preferred
2+ years of experience in a healthcare contact center, member services, or provider services role
Working knowledge of health insurance operations including eligibility, benefits, claims, prior authorizations, referrals, and appeals/grievances processes
Familiarity with CMS, TDI, NCQA, and HIPAA compliance requirements as they relate to member and provider services
Proficiency with EMR and payer portal systems; experience with Athena a plus
Exceptional customer service, communication, and active listening skills
Strong analytical and problem-solving skills with the ability to navigate multiple systems simultaneously
Ability to manage high call and case volume while maintaining accuracy and compassion
Demonstrated ability to work collaboratively across cross-functional teams
Strong attention to detail and documentation discipline
Preferred:
Experience in a payvider, integrated delivery system, or health plan environment
Familiarity with Medicare Advantage, Medicaid, ACA Marketplace, or employer group insurance products
Experience handling appeals, grievances, or regulatory complaint processes
Knowledge of medical terminology, CPT/ICD-10 coding, or claims adjudication
Bilingual in English/Spanish
WHAT WE OFFER
Competitive salary and incentives
Generous PTO
10 paid holidays
Medical, Dental, and Vision Insurance
401(k) Investment Plan
Company Equity
Professional development and growth opportunities
At Harbor Health, we're transforming healthcare in Texas through collaboration and innovation. We're seeking passionate individuals to help us create a member-centered experience that connects comprehensive care with a modern payment model. If you're ready to make a meaningful impact in a dynamic environment where your contributions are valued, please bring your talents to our team!
