Member Services Specialist

We are seeking a customer-focused Member Services Representative (MSR) to provide exceptional support to health plan members, providers, brokers, and business partners. This role serves as a key point of contact for inquiries related to health plan benefits, eligibility, claims, billing, referrals, and member resources.

• Respond to member inquiries regarding Commercial, Exchange, and Individual health plans via phone, email, chat, fax, and in-person visits.
• Assist members with questions related to benefits, eligibility, referrals, coverage, claims, and healthcare services.
• Educate members on available resources, self-service tools, and online member portals.
• Deliver professional, empathetic service while maintaining confidentiality and compliance with healthcare regulations.
• Investigate and resolve complex member issues requiring research and coordination with internal departments or external partners.
• Assist with urgent and sensitive cases involving access to care concerns and member advocacy needs.
• Accurately document member interactions and maintain detailed records within internal systems.
• Process and escalade appeals, grievances, and complaints according to established procedures and regulatory requirements.
• Provide information regarding claims processing, billing inquiries, and plan benefits.
• Assist members, providers, brokers, and healthcare partners with questions related to coverage and claim status.
• Collaborate with internal teams to ensure timely resolution of inquiries and concerns.
• Serve as a resource for fellow Member Services Representatives by sharing knowledge on plan benefits, policies, procedures, and system navigation.
• Participate in cross-functional initiatives to improve the member experience.
• Share feedback regarding recurring member concerns, system issues, and process improvement opportunities.
• Attend team meetings, training sessions, and system update discussions.

• High school diploma or equivalent required;
  Associate's or Bachelor's degree preferred.
• Minimum 2+ years of customer service experience, preferably in healthcare, health insurance, call center, or member services environments.
• Experience handling high-volume inbound calls and complex customer inquiries.
• Knowledge of health insurance terminology, claims, benefits, and eligibility processes preferred.
• Strong verbal and written communication skills.
• Excellent customer service and problem-solving abilities.
• Ability to de-escalate challenging situations with professionalism and empathy.
• Strong attention to detail and documentation accuracy.
• Ability to manage multiple priorities in a fast-paced environment.
• Proficiency in Microsoft Office and customer relationship management systems.
• Ability to work independently and collaboratively within a team environment.

Equal Opportunity Employer/Veterans/Disabled

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The Company will consider qualified applicants with arrest and conviction records in accordance with federal, state, and local laws and/or security clearance requirements, including, as applicable:

The California Fair Chance Act

Los Angeles City Fair Chance Ordinance

Los Angeles County Fair Chance Ordinance for Employers