Member Service Representative

Member Services Representative

Provides phone-based customer service support to health plan members by assisting with benefits, eligibility, claims, providers, pharmacy services, appeals, grievances, and general plan questions. Responsible for researching and resolving concerns, using de-escalation skills, documenting interactions, navigating multiple systems, and delivering excellent member service.

Key Responsibilities:

• Handle high-volume inbound member calls.
• Assist with benefit, claims, provider, pharmacy, appeal, and grievance inquiries.
• Resolve member concerns using empathy, problem-solving, and de-escalation skills.
• Document interactions accurately while maintaining HIPAA/PHI compliance.
• Navigate multiple systems and support AEP call volume.

Required Qualifications:

• Minimum 5 years of healthcare experience required, preferably in Medicare advantage plans, Health insurance, member services, claims, benefits, or customer service.
• Strong communication, multitasking, problem-solving, and de-escalation skills.
• Ability to protect confidential member information and navigate multiple systems.
• Ability to work independently in a remote environment after training.

Remote Requirements:

• Reliable high-speed wired internet (cable, fiber, or DSL); mobile hotspots and cellular 5G internet are not permitted.
• Basic technical skills to troubleshoot connectivity issues, set up equipment, and understand computer installation requirements.
• Ability to use dual monitors.

Work Location: Training onsite at KCA Pearland Administrative Office; position transitions to remote/hybrid after successful training and performance completion.

Schedule: Flexible availability between 8:00 AM8:00 PM, 7 days a week, including possible weekend coverage during AEP.