PacificSource Health Plans

  • Group Membership Representative II

    Job Location US-OR-Springfield
    Job ID
    Regular Full-Time
    Hiring Pay Range
    # of Openings
  • Overview

    Responsible for servicing a designated block of accounts by preparing billing statements for paid claims and administrative fees, processing eligibility transactions, payments and reconciling accounts as needed. Administer both fully insured and self-funded lines of business. Provide customer service to employer groups, members and related entities by providing assistance with eligibility, regulatory provisions, contract guidelines, billing administration and claims reporting.


    1. Process enrollment applications, changes, terminations, waivers and continuation forms for subscribers and dependents via billing statements, mail, email, fax, spreadsheet, 834 files, OES, InTouch and other formats. Use group contract, ASO Agreement, Summary of Plan Description or benefit book information to determine eligibility. Obtain missing information by contacting group administrators.
    2. Log into all states group department phone queues during scheduled shift, documenting all calls and responding to daily emails and voicemails. Assist members, group administrators, agents and PacificSource staff with eligibility, regulations, COBRA & state continuation administration, demographic changes, ID cards, calculation of group premium balances, and rate questions.
    3. Process electronic/lockbox deposits. Prepare and process manual deposits, as needed. Prepare spreadsheet setup, staging, and daily totals for Finance.
    4. Reconcile group balances as needed, and prior to renewal. Process Claims Pay Holds, Rating Overrides, Discretionary Billing Items, refunds, and write offs as needed.
    5. Review claims reports and create claim invoices on Excel spreadsheets or supply census reports to those groups who create their own self-bill, meeting strict timelines defined in the ASO agreement. Set up claims reporting for new ASO groups.
    6. Process system and invoice adjustments for ASO claim refunds and adjustments, over stop loss amounts and administrative fees. Reconcile reports, invoices and system files each funding period.
    7. Monitor delinquency of both self-funded and fully insured groups and pursue collections as needed. Initiate an escalation process for non-payers of self-funded groups. Assist employers or brokers with group policy reinstatement process.
    8. Administration of claims run-out provisions as defined by the ASO agreement
    9. Electronically upload images into imaging system. Prepare documents for manual imaging if needed.
    10. Meet with new and existing group administrators as requested by Sales, brokers,  and group administrators. Initiate visits to promote customer training and service.
    11. Process and maintain various eligibility and account status reports.
    12. Activate and update members with various pharmacy vendors systems.
    13. Create or update policy and procedures as requested.
    14. Maintain accuracy standards as required to meet department and PacificSource PRISM measures.

    Supporting Responsibilities:

    1. Process credit card payments as needed.
    2. Meet department and company performance and attendance expectations.
    3. Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
    4. Attend department meetings and mentor lessons as scheduled.
    5. Provide back-up coverage for other phone queues as needed.
    6. Perform other duties as assigned.




    Work Experience: Two years Accounting/Accounts Receivable experience with strong keyboarding and 10-key experience required. One year experience with customer service and insurance required. One year previous experience in Commercial Enrollment and Billing Department preferred. Requires intermediate level experience using Excel, creating formulas and performing data comparisons. Experience analyzing data and reports for accuracy.


    Education, Certificates, Licenses: Associate’s degree in business or accounting, or equivalent work experience.


    Knowledge: Ability to understand claims reporting for self-funded groups. Knowledge of group health insurance contract provisions, and administrative services agreement guidelines. Excellent verbal, phone and written communication skills.



    Our Values

    • Adaptability
    • Building Customer Loyalty
    • Building Strategic Work Relationships
    • Building Trust
    •  Continuous Improvement
    • Contributing to Team Success
    • Planning and Organizing
    • Work Standards



    • We are committed to doing the right thing.
    • We are one team working toward a common goal.
    • We are each responsible for our customers’ experience.
    • We practice open communication at all levels of the company to foster individual, team and company growth.
    • We actively participate in efforts to improve our communities-internal and external.
    • We encourage creativity, innovation, continuous improvement, and the pursuit of excellence.



    Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 5% of the time.


    Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions.  Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.


    Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.


    PacificSource is an equal opportunity employer.  All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.








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