Member Experience Representative I, TPA

Member Experience Representative I, TPA

Network Health's success is deeply rooted in its mission to build healthy and strong Wisconsin communities. This mission shapes every decision we make, including the selection of individuals who join our growing team. Our Member Experience Representative team embodies our commitment to Service Excellence and is dedicated to delivering exceptional customer service both verbally and in writing. This role is responsible for consistently providing accurate, courteous, and timely information to members, providers, brokers, and employers while ensuring each interaction reflects professionalism and care. Individuals in this position are expected to provide timely, accurate, and compassionate support while maintaining compliance with company policies, regulatory requirements, and operational standards. Success in this role requires strong communication skills, critical thinking, problem-solving abilities, and a commitment to delivering positive outcomes that enhance the overall member and provider experience. We strive to provide amazing service in plain language that our members will understand.

Location: Candidates must reside in the state of Wisconsin for consideration. This position is eligible to work at your home office (reliable internet is required), at our office in Brookfield or Menasha, or a combination of both with our hybrid workplace model. Hours: 1.0 FTE, 40 hours per week, 8am - 5pm Monday through Friday.

Job Responsibilities:

• Demonstrate commitment to Network Health's organizational culture, service standards, and member-first philosophy
• Apply all organizational, regulatory, credentialing, and compliance standards, including policies, procedures, and applicable regulations
• Respond to and resolve member, provider, broker, and employer inquiries through phone, portal, fax, and email channels
• Take ownership of each customer inquiry from initial contact through final resolution, ensuring timely and comprehensive follow-up
• Accurately document all customer interactions, issues, and resolutions in real time for legal, regulatory, and reporting purposes
• Meet or exceed established departmental performance goals, including speed to answer, call abandonment, member satisfaction, and first call resolution
• Facilitate referrals and connect customers with appropriate internal departments for escalated concerns, precertification, claims, appeals, or subrogation matters
• Produce timely and professional written correspondence to support issue resolution
• Maintain in-depth knowledge of assigned plan documents, Summary Plan Descriptions (SPDs), Administrative Services Agreements (ASA), employer group details, and departmental procedures
• Research and resolve complex issues across multiple databases while collaborating with internal departments and external vendors
• Effectively multitask across systems and platforms to ensure accuracy, compliance, and positive member outcomes
• Conduct outbound calls as necessary to resolve customer issues or provide additional support
• Educate members on available benefits, programs, and vendor resources to maximize plan value and promote overall wellness
• Support additional operational or departmental responsibilities as assigned

Job Requirements:

• High school diploma or equivalent
• A minimum of three years of customer service experience is preferred. TPA environment, health insurance or healthcare clinic experience is preferred.
• Telephone experience in a call center setting or phone support role is also preferred.
• Medical terminology background is a plus
• Excellent communication skills including the ability to clearly explain complicated subjects
• Warm and pleasant demeanor over the phone. We want our members to hear your smile!
• The ability to work in several computer systems and multi-screen set-up and know where to find answers

Network Health is an Equal Opportunity Employer