Sr. Call Center Member Service Representative

Published: 6/14/2022

Job Description

Sr. Member Service Representative

Healthcare is increasingly unaffordable for many Americans. Most people believe they have two choices: increasingly expensive, restrictive employer insurance, or an ACA plan that keeps getting pricier. Many don't know there's a third, smarter option.

WeShare Health is that option.

WeShare Health’s mission is to make healthcare simpler, more affordable, and more human. We're a nonprofit, faith-inspired healthcare sharing organization where members contribute monthly to share one another's eligible medical expenses. We're proudly not insurance, and that's the point.

Members access a national network of 1 million physicians at 30 to 60 percent less than comparable traditional insurance. Since 2018, WeShare Health has served more than 100,000 members and shared more than $50 million in medical expenses. Our purpose is clear: people before profit.

WeShare Health is led by senior executives with deep experience across for-profit and nonprofit enterprises. We’re rated 4.6 out of 5 on Google Reviews, rated 4.7 on Trustpilot by members and certified as a Great Place To Work® by our employees. If you have a bias for action, enjoy challenges, and want to challenge the status quo to make an impact in a massive industry, WeShare Health might be the place for you!

About This Role

The Senior Member Services Representative plays a critical role in delivering an exceptional experience to our members and serves as an experienced resource within the Member Services organization.

In addition to managing inbound and outbound member interactions, Senior Member Services Representatives are responsible for resolving complex and escalated member concerns, taking ownership of cases through resolution, supporting less experienced representatives, identifying operational trends, and partnering with internal departments to remove barriers impacting the member experience.

This position requires strong healthcare knowledge, advanced problem-solving skills, sound judgment, emotional intelligence, and a high level of accountability. Senior Representatives are expected to model our “We Got You” service philosophy by taking ownership of member concerns and doing everything reasonably possible to reach a resolution.

The ideal candidate thrives in a fast-paced contact center environment, is comfortable handling difficult and sensitive situations, and consistently demonstrates leadership without requiring a formal management title.

Key Responsibilities

Member Service & Complex Issue Resolution

Provide exceptional service to members through inbound and outbound telephone calls and other communication channels.
Serve as a senior-level resource for complex member questions involving program guidelines, eligibility, medical needs, pharmacy needs, billing, provider access, member responsibility, sharing determinations, and correspondence.
Handle escalated member calls and cases that require advanced research, judgment, de-escalation, or coordination across multiple departments.
Take end-to-end ownership of complex member issues and remain accountable for driving the issue toward resolution rather than unnecessarily transferring or redirecting the member.
Focus on achieving First Call Resolution (FCR) whenever reasonably possible while balancing accuracy, compliance, and the overall member experience.
Research issues across multiple systems, databases, documents, and internal resources to identify the root cause of member concerns.
Clearly explain healthcare terminology, program guidelines, billing processes, member responsibilities, and complex processes in language that members can easily understand.
Manage difficult or emotionally charged conversations professionally while demonstrating empathy, confidence, and sound judgment.
Recognize urgent, high-risk, VIP, or highly sensitive member situations and ensure they are escalated appropriately and without unnecessary delay.
Conduct outbound follow-up when necessary to ensure outstanding member concerns have been addressed and commitments made to members have been completed.

Case Ownership & Escalations

Manage complex cases requiring additional research, follow-up, documentation, or coordination with other departments.
Partner with internal departments such as Provider Services, Medical Bill Review, Enrollment, Retention, Compliance, Finance, Sales, and leadership to resolve member concerns.
Identify when an issue requires escalation and ensure the appropriate stakeholders receive complete and accurate information.
Maintain clear ownership of escalated cases and provide members with appropriate updates throughout the resolution process.
Ensure cases, notes, activities, and member interactions are documented thoroughly, accurately, and timely within applicable systems.
Review case history and previous member interactions before responding to ensure continuity and prevent members from having to repeatedly explain their situation.
Identify situations where standard processes are not adequately addressing the member's concern and escalate recommendations for alternative resolution when appropriate.

Senior-Level Team Support

Serve as a subject matter resource for Member Services Representatives regarding complex member questions, processes, systems, and program guidelines.
Assist less experienced representatives with complex calls and cases while helping them develop stronger problem-solving and member service skills.
Provide peer coaching and real-time guidance when appropriate.
Help reinforce department standards, service expectations, policies, and procedures.
Support new-hire onboarding, nesting, shadowing, and ongoing training initiatives as requested by leadership.
Demonstrate leadership through professionalism, dependability, attitude, accountability, and consistent performance.
Serve as a positive example of WeShare's service standards and “We Got You” culture.
Provide support during periods of elevated call volume, staffing shortages, operational challenges, or other business-critical situations.

Quality & Performance

Consistently meet or exceed department expectations related to quality, productivity, attendance, documentation, First Call Resolution, member satisfaction, and other established performance metrics.
Participate in quality assurance reviews, coaching sessions, calibration exercises, and ongoing training.
Help identify coaching opportunities and recurring knowledge gaps observed within the Member Services team.
Maintain a high level of accuracy when communicating program information and documenting member interactions.
Follow all applicable policies, procedures, compliance requirements, scripts, and communication standards.
Maintain proficiency across multiple products, programs, benefits, systems, and workflows.

Operational Improvement

Identify recurring member concerns, call drivers, process breakdowns, provider issues, system challenges, and operational trends.
Escalate recurring issues to department leadership with supporting examples and recommended solutions when appropriate.
Proactively identify opportunities to improve the member experience, reduce repeat contacts, improve First Call Resolution, and simplify internal processes.
Participate in department initiatives, pilots, process improvements, and special projects.
Provide frontline feedback regarding policies, systems, procedures, scripts, and operational changes.
Assist leadership in identifying the root causes of member dissatisfaction and opportunities to improve retention.
Communicate emerging trends or potentially widespread member-impacting issues to leadership promptly.

Contact Center Responsibilities

Remain available at the assigned workstation during scheduled call periods within an Automatic Call Distribution (ACD) environment.
Handle inbound and outbound interactions in accordance with established schedules, service levels, and productivity expectations.
Complete required call documentation, case notes, reports, follow-up activities, and research.
Participate in call monitoring and quality assurance programs.
Maintain schedule adherence and availability requirements consistent with department expectations.
Work assigned schedules and demonstrate flexibility to work overtime, evenings, weekends, or holidays when required based on business needs.

Required Qualifications

High School Diploma or GED required.
2+ years of customer service and/or contact center experience, preferably in a healthcare-related environment.
Demonstrated experience resolving complex customer or member concerns.
Demonstrated ability to independently research problems, identify root causes, and drive issues through resolution.
Strong written and verbal communication skills.
Strong interpersonal skills with the ability to communicate professionally with members, peers, leadership, and cross-functional partners.
Demonstrated ability to remain composed and effective during difficult, escalated, or emotionally sensitive conversations.
Ability to successfully manage multiple priorities, cases, systems, and member interactions in a fast-paced environment.

Preferred Qualifications

2+ years of healthcare, health insurance, health sharing, benefits administration, medical billing, provider services, or healthcare contact center experience.
Previous experience handling escalated customer or member concerns.
Experience mentoring, coaching, training, or supporting other customer service representatives.
Experience working with healthcare terminology, medical billing, benefits, eligibility, provider networks, pharmacy programs, or claims-related processes.
Strong understanding of customer service escalation and complaint resolution.
Demonstrated ability to build rapport quickly and respond to members with empathy, professionalism, and confidence.
Advanced listening skills with the ability to gather relevant information, identify the underlying concern, and anticipate additional member needs.
Strong analytical and problem-solving skills with the ability to evaluate information from multiple sources and determine an appropriate course of action.
Ability to translate complex healthcare terminology and processes into clear, step-by-step explanations members can understand.
Strong conflict-management and de-escalation skills.
Demonstrated ability to adapt communication style based on different member personalities and circumstances.
Experience identifying operational trends and recommending process improvements.
Strong attention to detail and documentation skills.
Proficiency with Microsoft Outlook, Word, and Excel.
Experience working within CRM, case management, telephony, or contact center platforms.
Ability to quickly learn and navigate multiple complex computer systems.
Ability to work effectively in a collaborative, team-oriented environment.
Demonstrated history of strong attendance, reliability, professionalism, and accountability.
Ability to work regularly scheduled shifts within our hours of operation, including scheduled lunches and breaks, with flexibility to adjust schedules and work overtime, weekends, evenings, or holidays based on business needs.
Successful completion of all required Member Services training programs and demonstration of proficiency with applicable systems, policies, products, and procedures.

What We Offer

Competitive hourly compensation and PTO.
Health, Dental, and Vision benefits.
403(b) with company match.
Opportunity to make meaningful improvements within the healthcare industry.
A fast-paced, collaborative environment with direct access to senior leadership and key stakeholders.
Opportunities for professional development and advancement within a rapidly growing organization.

WeShare Health is an Equal Opportunity Employer. Our business is fast-paced and will continue to evolve. As such, the duties and responsibilities of this role may be changed as directed by the Company at any time to promote and support our business needs. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, gender expression, national origin, protected veteran status, or any other basis protected by applicable law and will not be discriminated against on the basis of disability.