Member Services Representative

Member Services Representative – Healthcare

Sigma Inc. is seeking a Member Services Representative for an exciting temp-to-permanent opportunity in Irving, TX. This is an excellent opportunity for customer service professionals with experience in healthcare, health insurance, member services, call centers, claims, benefits, or provider support who enjoy helping customers resolve questions and navigate healthcare services.

Job Summary

The Member Services Representative will serve as a frontline resource for health plan members, providers, and brokers, providing professional, empathetic, and resolution-focused customer service. The representative will handle inquiries related to eligibility, benefits, claims, coverage, member portals, and healthcare services, with a strong emphasis on first-call resolution.

This role is well suited for candidates who can communicate complex healthcare information in simple terms, accurately document interactions, navigate multiple systems, and maintain performance standards in a fast-paced, metric-driven call center environment.

Key Responsibilities

• Respond to and resolve inquiries from health plan members, providers, and brokers.
• Support questions related to Health Exchange, US Family Health Plan, and NCHD lines of business.
• Provide basic eligibility and benefits information for Medicare Advantage inquiries.
• Resolve routine questions during the initial interaction using approved scripts, resources, and system navigation.
• Document member and provider interactions accurately in the CRM.
• Explain healthcare benefits, eligibility, coverage, and member rights and responsibilities clearly.
• Help members navigate the CHRISTUS website and member portal.
• Direct providers to approved electronic channels for eligibility and claims status, including 270/271 and 276/277 transactions.
• Interpret routine claim statuses and denial codes and explain them to members in plain language.
• Guide members to their Explanation of Benefits (EOB) when additional claim information is needed.
• Follow established crisis call protocols and escalation procedures.
• Protect member information and maintain HIPAA compliance during all interactions.
• Demonstrate knowledge of Fraud, Waste, and Abuse (FWA) requirements.
• Meet established call center performance metrics, including:
• Calls handled
• Average Handle Time (AHT)
• Average Hold Time
• Schedule adherence
• First-call resolution
• Advocate for members and help resolve issues involving access to care and healthcare services.
• Participate in training, skill assessments, and progressive learning programs.
• Support special projects and operational initiatives as assigned.
• Participate in scheduled overtime during periods of high call volume.

Required Qualifications

• High school diploma or GED required.
• Previous experience in customer service, member services, healthcare, insurance, or a call center environment.
• Strong verbal and written communication skills.
• Ability to explain complex information clearly and professionally.
• Excellent listening, problem-solving, and customer service skills.
• Strong attention to detail and accuracy in documentation and data entry.
• Ability to multitask and prioritize responsibilities in a fast-paced, metric-driven environment.
• Basic proficiency with Microsoft Word, Excel, and Outlook.
• Ability to learn CRM and proprietary healthcare systems quickly.
• Professional, empathetic, and customer-focused demeanor.
• Ability to work independently while contributing effectively to a team.
• Understanding of HIPAA, member rights and responsibilities, and FWA.
• Ability to work scheduled overtime when needed.
• Reliable internet access and ability to work remotely during designated work-from-home days or unexpected building closures.

Preferred Experience

Candidates with experience in any of the following environments are strongly encouraged to apply:

• Health insurance
• Health plan member services
• Healthcare customer service
• Insurance customer service
• Provider services
• Medical claims
• Benefits and eligibility
• Medicare Advantage
• Medicaid or health exchange
• Call center / contact center
• CRM-based customer support
• Healthcare portals
• Claims status and denial codes