Member Services Representative

Member Services Representative II

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

• 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.

• 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.

• 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.

• 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.

• 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

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

• Minimum of 2 years of customer service, member services, call center, healthcare administration, insurance operations, or related experience.
• Prior experience supporting Medicare members, health insurance plans, or healthcare-related services is strongly preferred.
• Experience working in a metrics-driven or performance-focused environment preferred.

Desired Skills & Competencies

Customer Service Excellence

• Exceptional communication and interpersonal skills.
• Demonstrated ability to build rapport and establish trust with members.
• Strong conflict resolution and de-escalation skills.
• Ability to display empathy while maintaining professionalism and efficiency.

Technical Skills

• Proficiency with Microsoft Windows applications and computer-based systems.
• Ability to navigate multiple software applications simultaneously while engaging with members.
• Experience with customer relationship management (CRM) platforms, case management systems, or healthcare administration software is preferred.
• Comfortable using VPN access, remote work technologies, headsets, and virtual communication tools.

Organizational Skills

• Strong attention to detail and accuracy in documentation.
• Excellent time management and prioritization abilities.
• Ability to manage a high volume of requests while maintaining service quality.

Critical Thinking

• Demonstrates sound judgment and decision-making capabilities.
• Ability to interpret policies, procedures, and benefit guidelines to resolve member concerns.
• Strong analytical and problem-solving skills.

Work Environment

• Primarily remote and telephone-based customer service environment.
• Extensive interaction with members throughout the workday.
• Fast-paced setting with performance expectations related to quality, productivity, and member satisfaction.
• Flexible schedule may be required to support business needs.

Physical Requirements

• Ability to sit for extended periods while working on a computer and handling member calls.
• Manual dexterity required for keyboarding and system navigation.
• Ability to occasionally bend, stoop, stretch, and lift up to 20 pounds.
• Must be able to effectively use a computer, headset, telephone, and standard office equipment.

Ideal Candidate Profile

The successful candidate will be a compassionate and detail-oriented customer service professional who enjoys helping others navigate healthcare-related questions and challenges. They will possess strong communication skills, thrive in a fast-paced environment, demonstrate accountability for results, and consistently deliver an exceptional member experience while maintaining compliance and confidentiality standards.

EEO Employer