Member Services Representative

Job ID: 9191479
Location: Irving, TX 75039 - Onsite
Schedule: Monday-Friday, 8:00 AM-5:00 PM
Job Type: Full-Time Contract

Job Summary:

Sigma Inc. is currently seeking a Member Services Representative to provide high-quality, resolution-focused support to health plan members, providers, and brokers. This role serves as a frontline representative responsible for handling healthcare-related inquiries, explaining benefits and eligibility information, assisting with claims-related questions, and ensuring excellent customer service through first-call resolution.

The ideal candidate will have experience in healthcare customer service, insurance, call center operations, or member support environments and will be comfortable working in a fast-paced, metric-driven setting.

Responsibilities:

• Serve as the primary point of contact for members, providers, and brokers regarding healthcare plan inquiries.
• Resolve questions related to eligibility, benefits, claims status, and coverage information.
• Support inquiries across multiple healthcare programs, including Health Exchange, Medicare Advantage, and other health plan services.
• Provide accurate benefit explanations using established guidelines and healthcare terminology.
• Assist members with navigating healthcare websites, portals, and online resources.
• Guide providers toward appropriate electronic channels for eligibility and claims inquiries.
• Document all member and provider interactions accurately in CRM systems, including issue details and resolutions.
• Maintain HIPAA compliance and protect confidential member information.
• Interpret routine claim statuses and denial information and explain next steps clearly to members.
• Follow call handling procedures, scripts, and quality standards while maintaining a customer-first approach.
• Meet performance expectations including call volume, average handle time, documentation accuracy, and schedule adherence.
• Participate in training programs, assessments, and continuous improvement initiatives.

Required Qualifications:

• High school diploma or GED required.
• 1+ year of customer service experience, preferably within healthcare, insurance, or a call center environment.
• Strong verbal and written communication skills with the ability to explain complex information clearly.
• Excellent problem-solving skills with a focus on first-call resolution.
• Strong attention to detail and accurate documentation skills.
• Ability to manage multiple systems and tasks in a fast-paced environment.
• Basic proficiency with Microsoft Office Suite (Word, Excel, Outlook).
• Ability to quickly learn healthcare systems, CRM platforms, and proprietary applications.
• Professional and empathetic communication style with strong customer service skills.
• Ability to work independently while collaborating effectively with a team.

Preferred Qualifications:

• Experience supporting health plan members or providers.
• Knowledge of healthcare benefits, eligibility, claims, and Explanation of Benefits (EOB).
• Experience working with Medicare Advantage, Medicaid, or commercial health insurance.
• Experience using CRM systems or healthcare member management platforms.
• Familiarity with HIPAA regulations and healthcare privacy standards.

Work Requirements:

• Monday-Friday, 8:00 AM-5:00 PM schedule.
• Ability to work remotely during scheduled work-from-home days or emergency closures.
• Reliable internet connection required for remote work.
• Flexibility to support overtime during high-volume periods.