Member Service Representative - Remote / Telecommute

Cynet systems Inc; Washington (District of Columbia); Remote; USD 40,000 - 55,000; Full time

Job summary

A service-oriented company in Washington, DC is seeking a Member Services Representative to deliver high-quality customer support. The ideal candidate will have a high school diploma and at least 1 year of experience in customer service or claims. Strong communication and organization skills are necessary to address member inquiries and ensure accurate claims processing. This position is essential in supporting managed care initiatives and billing transactions.

Qualifications

• Minimum 1 year of customer service or claims experience required.
• Experience in healthcare or health insurance preferred.

Responsibilities

• Answer member inquiries and provide accurate responses.
• Resolve member service problems and identify issues.
• Examine claims for compliance with policies and procedures.
• Calculate and address payment resolutions.
• Execute enrollment transactions as per guidelines.
• Generate accurate billing for policies.
• Administer various billing transactions through accounts.
• Collaborate with clients and providers for issue resolution.
• Identify clients for managed care interventions.

Skills

Organizational skills

Problem-solving skills

Written communication

Verbal communication

Customer service skills

Education

High School Diploma or GED

Job description

Job Description

The Member Services Representative will be responsible for providing excellent customer service by responding to member inquiries, processing claims accurately, executing enrollment transactions, and supporting managed care initiatives.

This role requires strong communication, organizational, and problem-solving skills to ensure high-quality service delivery.

Responsibilities

• Answer member inquiries by clarifying desired information, researching, and providing accurate responses.
• Resolve member service problems by identifying issues, researching solutions, and escalating unresolved concerns as needed.
• Examine claims to identify key elements, processing requirements, and ensure compliance with medical policy, contracts, and procedures.
• Calculate deductibles, maximums, and determine resolutions for overpayments, underpayments, and managed care processes.
• Learn and execute enrollment transactions following contractual and medical underwriting guidelines.
• Generate accurate billing for policies and products purchased by new and existing clients and transfers from other plans.
• Administer various billing transactions such as direct pay, credit card payments, and debit accounting through policyholder accounts.
• Collaborate with clients, group administrators, brokers, or providers for issue resolution.
• Identify clients eligible for managed care interventions and collaborate with clinical professionals to implement solutions.

Qualification And Education

• High School Diploma or GED required.

Experience

• Minimum 1 year of customer service, claims experience, or inbound call center experience.
• Experience in detailed tasks related to health care, health insurance, or medical information preferred.
• Direct service experience is an asset.

Skills

• Self-starter with strong organizational and planning skills.
• Excellent written and verbal communication skills.
• Strong problem-solving and analytical abilities.
• Ability to maintain effective interpersonal relationships.
• Proven ability to deliver high-quality customer service by following best practices and promptly responding to inquiries.