Member Services Representative

Position Summary

Provides personalized customer service to health plan members by phone or electronically, addressing questions and resolving concerns related to enrollment, benefits, eligibility, billing, claims, and authorizations.

Minimum Qualifications

• Education: High School Diploma or GED (required)

• Experience:

  • At least 1 year of customer service experience in call center, receptionist, or administrative support roles.

  • Experience in healthcare or health insurance preferred.

• Skills & Competencies:

  • Strong verbal and written communication skills.

  • Customer-first approach: empathy, confidence, proper tone, and professionalism.

  • Comfortable using Windows/computer systems (Plan Central, Macess systems preferred).

  • Ability to multitask in a fast-paced environment.

  • Knowledge (or ability to learn) of health insurance rules and regulations.

  • Confidentiality with member health and business information.

  • Flexibility with work hours.

Essential Functions

1. Handle inbound/outbound member inquiries regarding benefits, claims, authorizations, billing, and enrollment.

2. Document all inquiries in the tracking system and route to appropriate departments.

3. Meet/exceed call handling, quality, and productivity standards.

4. Use Empathy, Education, and Empowerment (Three Es) in all member communications.

5. Navigate and utilize Plan Central & Macess systems for resolution.

6. Perform duties with integrity and professionalism.

7. Exercise independent judgment and decision-making in problem-solving.

8. Manage moderate stress levels (multitasking, quotas, accountability for performance).