Member Services Rep

Member Services Representative

Education: HS Diploma or equivalent Required Qualifications Minimum of 5 years of healthcare experience required. Experience supporting Medicare Advantage plans, health insurance, member services, claims, benefits administration, or healthcare customer service strongly preferred. Excellent verbal and written communication skills. Strong customer service, multitasking, critical thinking, and problem-solving abilities. Demonstrated ability to effectively de-escalate difficult member interactions. Ability to safeguard confidential information and comply with HIPAA regulations. Comfortable working with multiple applications and systems simultaneously. Self-motivated with the ability to work independently in a remote setting after training. Technical Requirements Reliable high-speed wired internet connection (cable, fiber, or DSL required). Mobile hotspots and cellular/5G internet connections are not permitted. Basic technical proficiency, including the ability to troubleshoot connectivity issues, install computer equipment, and meet workstation setup requirements. Ability to work using dual monitors.

Job Summary We are seeking a dedicated Member Services Representative to provide exceptional customer service and support to health plan members. In this role, you will serve as the primary point of contact for members by assisting with benefits, eligibility, claims, provider searches, pharmacy services, appeals, grievances, and general health plan inquiries. The ideal candidate is an experienced healthcare customer service professional who thrives in a fast-paced call center environment, demonstrates strong problem-solving skills, and is passionate about delivering outstanding member experiences.

Key Responsibilities Handle a high volume of inbound calls from health plan members. Assist members with questions regarding benefits, eligibility, claims, provider networks, pharmacy services, appeals, grievances, and other health plan inquiries. Research and resolve member concerns efficiently while providing accurate information and excellent customer service. Utilize empathy, active listening, and de-escalation techniques to address challenging situations and ensure positive member outcomes. Accurately document all member interactions while maintaining HIPAA and PHI confidentiality standards. Navigate multiple computer systems simultaneously to access member information and complete documentation. Support increased call volume during the Annual Enrollment Period (AEP) while maintaining quality and productivity standards. Meet established performance metrics for quality, productivity, and member satisfaction. Work independently in a remote environment following successful completion of onsite training.

Work Environment Initial onsite training at the KCA Pearland Administrative Office is required. Position transitions to a remote or hybrid work arrangement upon successful completion of training and performance expectations. Candidates must maintain a professional home office environment suitable for handling confidential member information.