Member Service Representative

Member Services Representative III

Location: Sacramento, CA

Schedule: Full-Time

Position Overview

We are seeking a customer-focused Member Services Representative (MSR) to provide exceptional support to health plan members, providers, brokers, and business partners. This role serves as a key point of contact for inquiries related to health plan benefits, eligibility, claims, billing, referrals, and member resources.

Key Responsibilities

• Respond to member inquiries regarding Commercial, Exchange, and Individual health plans via phone, email, chat, fax, and in-person visits.
• Assist members with questions related to benefits, eligibility, referrals, coverage, claims, and healthcare services.
• Educate members on available resources, self-service tools, and online member portals.
• Deliver professional, empathetic service while maintaining confidentiality and compliance with healthcare regulations.
• Investigate and resolve complex member issues requiring research and coordination with internal departments or external partners.
• Assist with urgent and sensitive cases involving access to care concerns and member advocacy needs.
• Accurately document member interactions and maintain detailed records within internal systems.
• Process and escalate appeals, grievances, and complaints according to established procedures and regulatory requirements.
• Provide information regarding claims processing, billing inquiries, and plan benefits.
• Assist members, providers, brokers, and healthcare partners with questions related to coverage and claim status.
• Collaborate with internal teams to ensure timely resolution of inquiries and concerns.
• Serve as a resource for fellow Member Services Representatives by sharing knowledge on plan benefits, policies, procedures, and system navigation.
• Participate in cross-functional initiatives to improve the member experience.
• Share feedback regarding recurring member concerns, system issues, and process improvement opportunities.
• Attend team meetings, training sessions, and system update discussions.

Qualifications

• High school diploma or equivalent required; Associate's or Bachelor's degree preferred.
• Minimum 2+ years of customer service experience, preferably in healthcare, health insurance, call center, or member services environments.
• Experience handling high-volume inbound calls and complex customer inquiries.
• Knowledge of health insurance terminology, claims, benefits, and eligibility processes preferred.
• Strong verbal and written communication skills.
• Excellent customer service and problem-solving abilities.
• Ability to de-escalate challenging situations with professionalism and empathy.
• Strong attention to detail and documentation accuracy.
• Ability to manage multiple priorities in a fast-paced environment.
• Proficiency in Microsoft Office and customer relationship management systems.
• Ability to work independently and collaboratively within a team environment.

Benefit offerings include medical, dental, vision, life insurance, short-term disability, additional voluntary benefits, EAP program, commuter benefits, and 401K plan. Our program provides employees the flexibility to choose the type of coverage that meets their individual needs. Available paid leave may include Paid Sick Leave, where required by law; any other paid leave required by Federal, State, or local law; and Holiday pay upon meeting eligibility criteria.