Member Services Representative

Job Description

Job Description

Summary:

• Provides personalized service to members and promptly works to answer questions and resolve concerns. Coordinates with management and other departments to effectively address member needs.

Minimum Qualifications1. Formal Education Required

• High School Diploma or GED required

• College experience preferred

2. Experience & Training Required

• More than 1 year of experience performing similar responsibilities

• Relevant experience includes:

  • Customer service

  • Call center or administrative support experience

  • Background in Medicare and/or health insurance strongly preferred

3. Other Skills, Competencies, and Qualifications

• Demonstrated knowledge of customer service practices , including phone system operations and documentation workflows

• Strong written and verbal communication skills

• Ability to work in Windows-based environments and organize computer-based information

• Maintain a professional, decisive, and customer-first attitude with empathy and confidence over the phone

• Ability to operate standard office equipment , including:

  • Personal computer

  • Headset

  • WiFi and VPN access

  • Audio controls

• Strong keyboard and computer skills

• Ability to learn and apply knowledge of the health insurance industry , including governing rules and regulations

• Effective time management in a fast-paced environment

• Ability to follow regulatory, departmental, and company policies and procedures

• Maintain strict confidentiality of member health and business information

• Flexible schedule and ability to work in a remote environment

Essential Functions

1. Provide personalized service to members by phone, electronic communication, or in person regarding:

   • Enrollment

   • Benefits

   • Eligibility

   • Billing

   • Claims

   • Authorizations

2. Record all member inquiries and complaints in the tracking system with accurate documentation and proper routing.

3. Meet or exceed departmental production and quality standards for both telephonic and written communications.

4. Treat all customers with respect and empathy , using education and empowerment during every interaction.

5. Maintain knowledge of health insurance industry practices , including governing rules, regulations, and internal systems such as Amisys and Macess .

6. Perform job responsibilities with integrity , providing professional and cooperative service to internal and external customers.

7. Use independent judgment and problem-solving skills to resolve member concerns and interpret procedures appropriately.

8. Communicate effectively through written and verbal methods , maintaining confidence and a service-oriented tone over the phone.

9. Organize and manage time efficiently to meet deadlines in a fast-paced call center environment .

10. Maintain strict confidentiality of member health and business information and comply with all policies and regulations.

11. Demonstrate moderate complexity decision-making , using independent judgment and problem-solving according to the demands of the task and applicable procedures.