Member Services Specialist - HP Member Services

Member Services Specialist

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 OneCHRISTUS Competencies: Leader of Self, Leader of Others, or Leader of Leaders.
• Begin mastery of four core systems (e.g., HSP, HPS, HealthTrio, and Zelis) to independently resolve inquiries and complete calls with accuracy and confidence.
• Resolve member, provider, or broker inquiries across Health Exchange, US Family Health Plan, and NCHD. Quote basic eligibility and benefits for Medicare Advantage inquiries, with emphasis on provider-facing interactions.
• Become a subject matter expert as you build foundational knowledge in core plan structures and internal workflows.
• Resolve routine inquiries during initial contact using standardized scripting, system navigation, and clear documentation.
• Provide customer service excellence through engagement, effective listening skills, patience, and desire to resolve the question/issue.
• Document call interactions in the CRM with clarity, accuracy, and resolution details that support audit readiness and downstream coordination.
• Explain core benefits and eligibility using handbook-aligned language; assist members in understanding coverage and accessing services.
• Guide members through navigation of the CHRISTUS website and their individual member portal.
• Professionally redirect providers to approved electronic channels (portal, 270/271, 276/277) for eligibility and claims status, in alignment with policy.
• Demonstrate understanding of member's rights and responsibilities, FWA, and remain HIPAA compliant during member/provider interactions.
• Maintain agent performance expectations during the first 0–6 months, including total calls handled, average call handle time, average hold time compliance, and schedule adherence.
• Demonstrate ability to interpret claim statuses in CRM, explain routine denial codes in plain language, and guide members to their EOBs for further detail and resolution.
• Advocate on the part of the beneficiary to resolve any issue with care.
• Ability to follow crisis call protocols with proficiency and care.
• Support and deliver assigned projects under leadership direction, contributing to team goals and operational excellence.
• Participate in progressive training modules and skill assessments that support career advancement within Member Services.
• Must have strong verbal and written communication skills, with the ability to convey complex information clearly and professionally.
• Must have the ability to multitask and manage time effectively in a fast-paced, metric-driven environment.
• Must demonstrate attention to detail and accuracy in documentation and data entry.
• Must have ability to work collaboratively in a team setting while independently managing assigned tasks.
• Must have professional demeanor and customer-first mindset, with a focus on empathy, patience, and problem-solving.
• Must have ability to participate in scheduled overtime during high-volume periods.
• Must have ability to work remotely on scheduled work-from-home days and during unscheduled building closures (e.g., inclement weather, power outages, or emergency events), with reliable internet access and adherence to all remote work protocols.

Job Requirements:

Education/Skills • High school diploma or equivalent is required. • Basic proficiency in Microsoft Office Suite (Word, Excel, Outlook) and ability to learn proprietary systems quickly.

Experience • 0–2 years of customer service experience preferred, ideally in healthcare, insurance, or call center environments.

Licenses, Registrations, or Certifications • NA

Work Schedule: 8AM - 5PM Monday-Friday

Work Type: Full Time