Member Specialist Services

About the job Member Specialist Services

Job Summary

Must have excellent understanding of benefits, products and other health care and/or insurance issues as they pertain to customers (internal/external). This position is to provide service and support to managed care customers through verbal or written communication.

This position acts as the primary liaison both telephonic and in-person between all members and the plan.

The Member Services Specialist serves as a frontline ambassador for the health plan, delivering high‑quality, resolution‑focused support to members, providers, and brokers across multiple lines of business.

As the initial point of contact, this role extends beyond basic call handling. Specialists are trained to navigate the foundational pillars of our healthcare offerings, including the Health Exchange, US Family Health Plan, and NCHD, with a strong emphasis on first‑call resolution.

Specialists develop working knowledge of benefit structures, assist callers with portal navigation and access, and begin interpreting claims activity to support both member and provider inquiries. This position blends customer service excellence with technical skill‑building, offering exposure to internal systems, regulatory protocols, and cross‑functional workflows.

Specialists are expected to gain proficiency in core platforms used for eligibility verification, claims review, and member account management (e.g., HSP, HPS, Health Trio). All interactions must be documented with a clear and concise recap of the call’s purpose.

• Facilitates member & provider to understand the plan coverage and benefits by thoroughly researching inquiries in an efficient and professional manner.
• Records all contact with customers, both verbal & written in the current MIS system.
• Required to assist in training / re‑training new and current employees.
• Maintains accurate documentation of all telephone contact, walk‑in customers, and any mail inquiries to ensure a clear audit trail for reporting purposes.
• Responsible for handling all incoming calls and making outgoing calls as needed to resolve any issues or questions.
• Triage phone requests to other areas such as Utilization Management and Provider Relations.
• Handles incoming written correspondence in a timely and professional manner.
• Excellent communication and knowledge of MIS system.

• High School Diploma or equivalent required.
• Proficiency in Microsoft Word and Microsoft Excel.

• Healthcare
• Insurance
• Insurance Claims
• Claims Adjusting