Member Services Representative (Healthcare)

Job Title: Call Center Associate Provider & Member Support (TPA Services)

Working Hours:

1. Operations run from 7 AM to 9 PM CST, 7 days a week.
2. Your 8-hour shift can fall anytime within these hours.
3. Weekly offs will be any two consecutive days (e.g., off on Mon Tue and work Wed Sun).

Position Summary:

We are looking for customer-focused Call Center Associates to handle inbound and outbound calls from providers and members as part of our Third-Party Administrative (TPA) services.
The role involves assisting healthcare providers, members, and prospective beneficiaries with inquiries related to benefits, claims, eligibility, and authorizations ensuring a high-quality experience in line with CMS compliance and STAR rating requirements.

Key Responsibilities:

1. Handle inbound provider calls regarding claim status, billing, network participation, and pre-authorizations.
2. Address member inquiries related to benefits, eligibility, enrollment, and claims.
3. Support CMS secret shopper and STAR rating-related interactions.
4. Document all call details accurately in the CRM system.
5. Ensure compliance with HIPAA and CMS standards.
6. Escalate complex issues promptly to the appropriate teams.
7. Use certified interpreter services for non-English calls.
8. Participate in ongoing training to stay current on CMS regulations and benefit plans.
9. Meet or exceed performance metrics: Call Quality (98%), AHT, FCR, and schedule adherence.
10. Collaborate with compliance and quality teams for continuous improvement.

Qualifications & Skills:

1. High School Diploma or GED required; Associate/Bachelor s degree preferred.
2. 1 2 years of call center experience, preferably in healthcare or insurance (TPA environment).
3. Familiarity with CMS guidelines, STAR ratings, and healthcare claims is an advantage.
4. Strong communication, multitasking, and problem-solving skills.
5. Experience using CRM systems and call center tools.
6. Detail-oriented, empathetic, and customer-centric mindset.