Job Overview
The Customer Service Member Support Rep serves as the frontline member advocate and primary point of contact for Detego Health members. This role assists members with routine questions regarding eligibility, benefits, claims, billing, provider networks, pharmacy benefits, and available member resources while delivering a professional, empathetic, and member-focused experience.
Customer Service Member Support Rep team members work within established procedures, workflows, and service standards to resolve routine inquiries, educate members regarding their coverage, accurately document interactions, and escalate complex or unresolved concerns as appropriate.
This is a non-clinical customer service position focused exclusively on health insurance navigation and member advocacy. Customer Service Member Support Reps do not provide medical advice, diagnose medical conditions, recommend treatments, interpret clinical information, or deliver healthcare services.
Duties
· Serve as the first point of contact for member inquiries via telephone, email, and other approved communication channels.
· Deliver a positive, professional, empathetic, and member-focused experience during every interaction.
· Verify member identity and protect confidential information in accordance with HIPAA and company privacy requirements.
· Educate members regarding eligibility, enrollment, benefits, claims, billing, provider networks, pharmacy benefits, prior authorizations, reimbursement programs, and available member resources.
· Research and resolve routine member inquiries using approved systems, knowledge bases, and internal resources.
· Accurately document all member interactions in Salesforce CRM and other required systems.
· Conduct outbound calls for follow-up, education, issue resolution, and member engagement as assigned.
· Escalate complex, sensitive, or unresolved issues to appropriate internal resources or higher-level Care Guides.
· Meet departmental standards for quality, productivity, average handle time, first call resolution, documentation accuracy, schedule adherence, attendance, and compliance.
· Participate in training, coaching, team meetings, and continuous improvement activities.
· Perform other related duties as assigned.
Skills
Customer Service
· Excellent customer service, communication, active listening, conflict resolution, and de-escalation skills.
· Ability to build rapport and provide an exceptional member experience.
Call Center
· Ability to work in a fast-paced, metrics-driven call center environment.
· Ability to handle consecutive inbound and outbound calls while balancing efficiency, quality, and accuracy.
Technical Skills
· Strong computer navigation skills and ability to work across multiple applications and monitors simultaneously.
· Strong documentation, data entry, and CRM/case management system skills.
· Ability to learn new software systems and internal processes quickly.
Health Insurance Knowledge
· Understanding of eligibility, enrollment, benefits, claims, provider networks, pharmacy benefits, deductibles, copayments, coinsurance, out-of-pocket maximums, prior authorization, and Explanation of Benefits.
· Ability to educate members about benefits without providing medical advice.
Critical Thinking
· Strong analytical and problem-solving skills.
· Sound judgment when handling confidential, sensitive, or escalated member information.
Work Environment
This is an in-office, member-facing health insurance customer service position in a fast-paced call center environment. Care Guides spend the majority of the workday assisting members by telephone while navigating multiple computer systems and documenting interactions.
This position does not provide healthcare services, medical advice, diagnosis, treatment recommendations, nursing services, or clinical decision-making.
Physical Requirements
· Ability to remain seated for extended periods.
· Frequent computer and headset use.
· Frequent keyboarding and viewing multiple monitors.
· Occasionally lift up to 15 pounds.
Equal Employment Opportunity / ADA Statement
Detego Health is an equal opportunity employer. The designation of essential functions and other duties is for compliance with the Americans with Disabilities Act and does not limit the duties, responsibilities, or qualifications for this position. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the role, absent undue hardship.
Pay: $20.00 - $22.00 per hour
Benefits:
- 401(k) matching
- Dental insurance
- Employee assistance program
- Health insurance
- Paid time off
- Vision insurance
Work Location: In person
