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Member Service Representative

Human Resource Advantage, LLC Miami Full-Time
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HealthSun Health Plans www.healthsun.com is seeking energetic,talented and qualified professionals to join us in our mission of changing the healthcare experience of our members - making it easier, friendlier and more accessible.  If you are looking for a challenging and rewarding career with a chance to make a real difference in your community, please apply.
HealthSun Health Plans is headquartered in the Coconut Grove area of Miami, Florida supporting the needs of Medicare Advantage recipients throughout South Florida. We are proud to offer outstanding career advancement opportunities, competitive salaries, paid holidays, medical & dental insurance plans, Paid Time Off, disability benefits, and a 401(k) retirement savings plan.
The Member Service Representative is responsible for ensuring continued member retention, growth and satisfaction by providing quality and professional service, in accordance with HealthSun Health Plans policies and procedures, during every Member Services Department interaction, be it via telephone, written correspondence or in person.
  • Handles telephone, written and in-person inquiries in a courteous, professional, thorough manner with the goal of ensuring member satisfaction. 
  • Assists callers with, but not limited to, coverage decisions, grievances, appeals, benefit interpretation and utilization, eligibility verification, provider network availability, primary care physician changes, plan rules, referrals or authorizations, and fulfillment of member materials. 
  • Responsible for meeting expectations established for call center key performance indicators, such as, but not limited to abandonment rate, average handle time and service level. 
  • Is knowledgeable of both Plan and Medicare benefits, CMS regulations and guidelines, and Plan policies and procedures.
  • Applies high level of subject matter knowledge to solve a variety of common business issues. 
  • Provides effecively provides a quality service experience during every interaction in order to increase overall customer service satisfaction levels as defined and measured by CMS.
  • Identifies when an interaction involves a grievance, appeal or coverage decision and correctly handles the interaction in accordance with the appropriate process.
  • Identifies, handles, documents and/or escalates Utilization Management inquiries as appropriate.
  • Identifies, handles, documents and/or escalates all Part C and Part D inquiries, coverage decision requests, and complaints as appropriate. 
  • Approaches work in a thorough manner, pays attention to detail and adheres to department job-aids, policies and procedures.
  • Is attentive to and responds effectively and efficiently to the needs of prospective, current, and former members and their representatives.
  • Keeps files and work area organized. 
  • Manages time effectively and prioritizes tasks to meet deadlines. 
  • Is flexible and can adjust to shifting priorities. 
  • Communicates effectively with other professional and support staff in order to meet individual and departmental objectives and achieve positive customer outcomes.
  • Promotes and contributes to a positive, problem-solving environment.
  • Assists customers, family members and others with concern and empathy; and communicates with them in a courteous and respectful manner.
  • Complies with company policies and procedures.
  • Maintains confidentiality of member protected health and personably identifiable information and ensures compliance with all HIPAA, OSHA, and other federal, state and local regulations.
  • Participates in meetings, trainings and in-service education, as required.
  • Performs all other duties as assigned.
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
  • Minimum of High School diploma or equivalent
  • Minimum of 1 year healthcare experience is required, with a preference for plan experience
  • Working knowledge of the Privacy and Security Health Insurance Portability and Accountability Act (HIPAA) regulations
  • Excellent communication skills, attention to detail, ability to set priorities appropriately and meet strict deadlines and the ability to manage multiple tasks simultaneously is required
  • Excellent listening, interpersonal, verbal and written communication skills with individuals at all levels of the organization
  • Excellent computer knowledge is required, including proficient knowledge of Microsoft Office
  • Familiarity with healthcare laws, regulations and standards
  • Must be patient in dealing with an elderly population and sympathetic to hearing or vision deficiencies
  • Ability to work with very little supervision and in a team environment
  • Ability to read, analyze, and interpret governmental regulations and guidelines
  • Ability to effectively present information and respond to questions from groups of managers, clients, customers and the general public
  • Ability to calculate figures and amounts, such as discounts, interest, commissions, proportions, percentages, area and volume
  • Ability to define problems, collect data, establish facts, and draw valid conclusions
  • Strong decision-making and analytical skills
  • Must be self-motivated, organized and have excellent prioritization skills
  • Must be able to work well under stressful conditions
  • Must be able to work in a fast paced environment
  • Fluency in Spanish and English required (verbal & written)
Working Conditions:
The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
  • Remote position
  • Remote physical space needs to meet appropriate conditions as defined by the employer, including but not limited to sound isolation, privacy, space for equipment provided by the employer
  • WIll be required to visit the home office, upon request by the employer, in order to participate in meetings, trainings and in-service education, as required
  • Remote home visit may be required to evaluate appropriateness of working conditions
  • Fast paced office environment
  • Highly regulated environment
  • Interacts with members, family members, staff, visitors, government agencies, etc., under a variety of conditions and circumstances
  • May be subject to interactions with emotionally upset customers, family members, providers, visitors, etc.
HealthSun Health Plans and its affiliated companies is an equal opportunity/affirmative action employer and complies with all federal and state laws, regulations and executive orders regarding affirmative action requirements in all programs.M/F/D/V.
HealthSun and its affiliates are also a drug-free workplace.
*Internal candidates must submit the Internal Application Form approved by his/her supervisor before interviewing with HR. Qualified candidates will be considered by the Hiring Manager


Skills required

Customer Service
Telephone Consultations
Answer Question
Membership Policies
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