Member Services Specialist

9126747 Member Services Specialist, Irving, TX, 3 Months temp to permanent
Sigma Inc. is currently looking for a Member Services Specialist to work onsite with our team in Irving, TX.

Shift Timings : Monday to Friday 8 am to 5 PM

Summary:

• The Member Services Specialist serves as a frontline ambassador for the health plan, delivering high-quality, resolution-focused support to members, providers, and brokers across multiple lines of business.
• As the initial point of contact, this role extends beyond basic call handling—Specialists are trained to navigate the foundational pillars of our healthcare offerings, including the Health Exchange, US Family Health Plan, and NCHD, with a strong emphasis on first-call resolution.
• Specialists develop working knowledge of benefit structures, assist callers with portal navigation and access, and begin interpreting claims activity to support both member and provider inquiries.
• This position blends customer service excellence with technical skill-building, offering exposure to internal systems, regulatory protocols, and cross-functional workflows.
• Specialists are expected to gain proficiency in core platforms used for eligibility verification, claims review, and member account management (e.g., HSP, HPS, HealthTrio).
• All interactions must be documented with a clear and concise recap of the call's purpose, following prescribed workflows and audit-ready standards.
• This role provides a structured pathway for advancement, with progressive training in claims interpretation, premium payment processing, and multi-line service delivery, laying the foundation for future specialization and leadership opportunities.

Responsibilities:

• Meets expectations of the applicable client competencies: leader of self, leader of others, or leader of leaders.
• Respond to inbound calls, emails, and member chat messages regarding healthcare-related questions and concerns.
• Adhere to established service level agreements (SLAs) and quality standards to consistently deliver excellent customer service about insurance benefits, claims, coverage, and other related inquiries.
• Assist members in navigating the healthcare system and understanding their rights and responsibilities.
• Investigate and resolve member complaints, issues, and escalations promptly and satisfactorily. Document all customer interactions and issue resolutions accurately and comprehensively in the CRM system.
• Collaborate with internal departments to facilitate issue resolution and ensure a seamless customer experience.
• Explain insurance plans, policies, and procedures to members, ensuring they understand their benefits and coverage clearly.
• Provide guidance on accessing healthcare services, locating in-network providers, and understanding pre-authorization requirements.
• Continuously enhance product knowledge and stay updated on industry trends and changes. Identify process improvement opportunities and provide recommendations to enhance the overall member experience.
• Proactively contribute to the development and implementation of customer service best practices.
• Collaborate with team members and management to improve operational efficiency and streamline workflows and customer satisfaction. Support USFHP, HIX, and NCHD LOB as needed.
• Participate in training sessions and professional development activities to enhance knowledge and skills.

Requirements:

• A High School diploma or equivalent is required. 0-2 years of customer service experience is preferred.