Customer Service Representative



Member Services

Reports to:

Operations Supervisor


Entry level, fully trained Member Services Representative to respond to member/provider inquires, whether of a substantive nature, a procedural nature, or both. The position provides customer service to all inbound calls as well as making outbound/outreach calls when necessary. All calls routed through an Automatic Call Distribution (ACD) system, from members and/or providers on a variety of topics to educate them on benefit issues, claims inquiries and collect feedback.


  • Complies with HIPAA/PHI regulations in all interactions with internal (representative from other departments) as well as external (members/providers).
  • Handles and/or exceeds average of 45 inbound calls a day, while meeting the service standards.
  • Ability to meet the minimum QA audit scoring criteria. 80% or higher
  • Attends to the members/providers inbound calls to assist with any appropriate information about benefits, provider and customer service issues.
  • Documents details of all calls in the appropriate system and routes issues to appropriate department for follow up, when/if necessary.
  • Follows up on pending unresolved issues.
  • Provides expertise and customer service support to internal customers.
  • Documents complaints and grievances in the appropriate systems and forwards to the appropriate entities.
  • Meets and maintains tardiness and attendance standards set by department policy.
  • Performs other duties and activities as deemed necessary.
  • Performs other duties as assigned.

Minimum requirements:

  • Ability to quickly and easily develop relationships
  • Must be able to multitask and be prepared to manage a wide variety of responsibilities that can change on a daily basis
  • Must work well with internal and external resources and counterparts
  • Strong team player that is focused with a strong work ethic
  • Excellent written and verbal communication skills
  • Microsoft office expertise – word, outlook and excel
  • Excellent interpersonal skills.
  • Professional organizational, oral and written communication skills.
  • Ability to listen, document and track problems within the appropriate systems, simultaneously while on calls.
  • Ability to respond in difficult situations on the telephone calls. Maintain flexibility and a “can do” attitude supporting department goals and objectives.
  • Able to commit to overtime as needed and/or shift changes.
  • Successfully complete in-house training program (90% or better on final test).

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