Member Services Representative - 3053178

Job#: 3053178

Job Description:

We are seeking a customer-focused and empathetic Member Services Representative II to serve as a trusted resource for members seeking assistance with their healthcare benefits and insurance-related inquiries. This individual will play a critical role in delivering a high-quality member experience by providing accurate information, resolving issues efficiently, and ensuring compliance with healthcare regulations and company standards.

The ideal candidate will have previous experience in a customer service or call center environment, possess strong communication skills, and demonstrate the ability to navigate complex healthcare and insurance-related questions. This role requires a balance of professionalism, problem-solving abilities, empathy, and attention to detail while supporting members through a variety of benefit and coverage inquiries.

Key Responsibilities

Member Support & Customer Service

• Serve as the primary point of contact for members via phone, email, and other communication channels.
• Assist members with questions related to health insurance benefits, eligibility, enrollment, claims processing, billing inquiries, authorizations, and coverage concerns.
• Provide personalized support while educating members on available benefits, programs, and resources.
• Resolve member issues efficiently while ensuring a positive customer experience during each interaction.
• Escalate complex issues to appropriate internal departments and coordinate resolution efforts on behalf of members.

Case Management & Documentation

• Accurately document all member interactions, concerns, complaints, and resolutions within internal tracking systems.
• Maintain detailed records that comply with organizational standards, regulatory requirements, and quality assurance guidelines.
• Track open issues and monitor follow-up activities to ensure timely resolution.

Quality & Performance

• Consistently meet or exceed established service-level goals, productivity metrics, quality standards, and member satisfaction expectations.
• Demonstrate professionalism, empathy, and active listening during all member interactions.
• Utilize proper call-handling techniques while effectively managing multiple priorities in a fast-paced environment.

Compliance & Industry Knowledge

• Maintain a strong understanding of health insurance products, Medicare guidelines, eligibility rules, claims processes, and industry regulations.
• Stay current on changes in healthcare regulations, organizational policies, and operational procedures.
• Handle protected health information (PHI) and confidential business information in accordance with HIPAA and company privacy standards.
• Ensure compliance with all departmental, regulatory, and organizational requirements.

Collaboration & Problem Resolution

• Partner with internal departments including Enrollment, Claims, Billing, Care Management, and Provider Relations to resolve member concerns.
• Use analytical thinking and independent judgment to determine appropriate solutions based on policy and procedure.
• Identify trends in member concerns and provide feedback that may improve processes or member satisfaction.

Required Qualifications

Education

• High School Diploma or GED required.
• Associate's degree or some college coursework preferred.

Experience

Minimum of 2 years of customer service, member services, call center, healthcare administration, insurance operations, or related experience.

Prior experience supporting Medicare membe