Member Services Representative III

Job Summary

Position is responsible for answering a high volume of inbound and outbound calls in a timely manner. Respond to all communications coming to Member Services in the form of email, fax, letters, and phone calls. Timely responses to all member communication are essential. Must effectively prioritize and flex the workload as new communication and task are submitted. Identify caller’s needs, clarify information, research every issue, and provide solutions and /or alternatives whenever possible. Keep records of all conversations in our call center database in a comprehensible way. This role is a part of the Member Services department and reports to the Member Services Supervisor.


Typical essential functions include but are not limited to Explaining the plans benefits, procedures, & services to:

  • Providers and employers requesting benefits, eligibility, authorization for outpatient surgery, Member’s claims concerns, or referral requests to other network providers Hospital admission and pre-admit authorization requests
  • Members with eligibility issues, COBRA, claims & other concerns regarding their coverage
  • Pharmacies with eligibility issues, drug authorization, drug co-pays, research of RX claims issues
  • Maintain follow-up on phone logs, claim research, eligibility, medical, dental, vision, and prescription plan issues
  • Review member service procedures, publications, daily for on-call member resolution
  • Maintain member satisfaction and retention via rapport building and proper identification of member, employer, provider, and service representative needs
  • Must be fluent English/Spanish (reading, writing, and speaking)
  • Mistakes must be kept below 2% of a daily basis for quoting incorrect information or errors in daily logs
  • Review member service procedures, publications, daily for one-call member resolution
  • Provide support to new members of the team
  • Generates weekly/monthly reports as needed
  • Supports departmental lead in his/her absence

Skills Assessment

Technical Skills

  • 5 or more years of experience in health care and claims related to position and knowledge of medical terminology
  • High School diploma required; college level course work preferred in Healthcare Administration.
  • Excellent skills with Microsoft Office products, which include Word, Excel, Outlook, PowerPoint, Microsoft Teams, Zoom and Smartsheets
  • Experience in working the following fields: Healthcare Benefits plans, Billing and Coding, Customer Service call center experience and able to answer a minimum of 70+ calls per day.


  • Excellent decision making, analytical skills, ability to think constructively, interpersonal skills, and demonstrated ability to deal with complex and changing situations
  • Outstanding writing, and verbal/nonverbal communication skills
  • Ability to work under pressure on competing priorities and in limited and changing timeframes, problem solving skills
  • Team building skills; self-motivated, and contributes productively the team
  • Career experience in healthcare industry is a plus

Work Environment / Physical Requirements

The physical demands and work environment described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to communicate by phone, email and in person with other staff members. There may be required times when the employee will need to work remotely based on the needs of the business. The employee must be able to have a distraction free area to preform required work duties during working hours. Employees should be able to perform the duties of the job in a seated position for a long duration of time. The employee may be required to lift boxes from 20 pounds to a maximum of 50 pounds, depending on the role.


Date Posted

Monday, November 1, 2021