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Case Resolution Specialist I
Exempt or Non-ExemptExempt
Research and respond to member and provider appeals, complex complaints, grievances and inquiries relating to all aspects of health plan coverage consistent with contract, regulatory and/or accreditation requirements. Seeks management guidance and supervisor/manager direction as needed.
- Bachelor's degree and one year of related work experience; or equivalent combination of education and related work experience.
- Proficient in using Microsoft Office applications.
- Effective verbal and written communication skills.
- Problem identification and resolution skills.
Duties and Responsibilities
- Conducts critical analysis of highly complex and sensitive member and provider appeals, inquiries and grievances and applies internal policies and procedures, contractual provisions, and regulatory requirements.
- Secures information from internal and external resources to resolve issues.
- Assists Supervisor and Coordinator in working as a liaison with providers, members and internal decision makers in representing HMSA objectives, goals, and expectations for meeting contractual, regulatory, and accreditation requirements.
- Negotiates/resolves sensitive issues with internal and external parties.
- Takes all facts and research from internal and external resources and presents a full explanation of the member's or provider's position and concerns to management and decision makers.
- Triages cases to resolve them upon initial inquiry to best service the member as well as minimize the number of cases escalated to senior management and executives
- Identifies when changes to policies and procedures are needed based on case resolutions, statutory or regulatory changes, or accreditation requirements.
- Proposes changes to management based on identification and analysis.
- Analyzes and identifies issues that may require multiple department efforts to resolve.
- Presents recommendations to internal committees, subgroups and executive management for decision making purposes as it relates to cases after discussion and approval from Supervisor and Coordinator.
- Assists with the implementation of resulting decisions for change/resolution.
- Assists supervisor/manager in responding to internal investigations, reviews, and audits; regulatory inquiries; and accreditation related audits.
- Assist internal customers with complex member/physician inquiries with guidance and direction from management.