Job Summary:
In addition to the responsibilities listed below, this position also coordinates the resolution of grievances and appeals cases by investigating, communicating with members and their advocates both verbally and in writing, preparing presentations of all relevant documentation to medical committees for medical service determinations and reconsiderations; identifying and partnering with appropriate entities to process escalations with an elevated level of complexity and a heightened level of resolution; reviewing cases and confirming case review documentation is prepared during decision making processes; leveraging a working knowledgeof the product/service domain to contribute to satisfactory resolutions of standard customer and member grievances and appeals with appropriate groups and departments (e.g., Medical Group, Health Plan); resolving issues for members related to health care delivery, benefits, or financial barriers by collaborating with cross functional partners in order to resolve member challenges; recognizing service gaps that contribute to dissatisfaction among customers, members, key stakeholders and/or functional areas with some guidance; making decisions on appropriate case types using critical thinking taking into account policy and guidelines; and ensuring that all case management activities are compliant with external regulations and responses to regulators.

Essential Responsibilities:

Pursues effective relationships with others by sharing resources, information, and knowledge with coworkers and members. Listens to, addresses, and seeks performance feedback. Pursues self-development; acknowledges strengths and weaknesses based on career goals and takes appropriate development action to leverage / improve them. Adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work. Assesses and responds to the needs of others to support a business outcome.

Completes work assignments by applying up-to-date knowledge in subject area to meet deadlines; follows procedures and policies, and applies data and resources to support projects or initiatives with limited guidance and/or sponsorship. Collaborates with others to solve business problems; escalates issues or risks as appropriate; communicates progress and information. Supports the completion of priorities, deadlines, and expectations. Identifies and speaks up for ways to address improvement opportunities.

Performs member, customer, or employee incident case management by: managing and monitoring own cases in the case tracking database to identify standard incident cases that require resolution as well as reporting trends to management; processing incoming standard incident cases by following general instructions; and ensuring compliance of own work with internal and external rules in the performance of case management activities with minimal guidance.

Performs member or employee incident case research by: researching claims, authorizations, member contracts, and/or customer service interactions across members and customers to make determinations for standard incident cases with little guidance required.

Resolves member or employee incident cases by: making decisions regarding standard incident cases through interacting with business leaders and other stakeholders; and resolving standard incident cases and implementing case decisions with some guidance.

Performs customer service by: providing accurate information to members, customers, employees or other stakeholders related to the status and outcomes of standard cases in an appropriate timeframe; and communicating with and diffusing frustrated members, customers, or other stakeholders in standard cases involving highly charged, sometimes emotional situations.

Performs case documentation by: maintaining confidentiality of member, customer, or employee information throughout numerous documentation activities for standard member cases; and documenting standard cases in accordance with all internal and external requirements with little supervision required.

Minimum Qualifications:

Minimum one (1) year of experience in customer service or a directly related field.

Bachelors degree in Business Administration, Economics, Health Care Administration, Health Services, Communications, or related field. OR Minimum three (3) years of experience in health care, health insurance, sales and marketing, or a directly related field.

Additional Requirements:

Knowledge, Skills, and Abilities (KSAs): Information Gathering; Negotiation; Incident Management; Health Care Compliance; Maintain Files and Records; Data Entry; Acts with Compassion; Interpersonal Skills; Managing Diverse Relationships; Relationship Building; Stakeholder Management; Incident Escalation; Managing Complexity; Time Management; Service Focus; Adaptability; Stress Tolerance; Member Service; Patient Safety; Microsoft Office; Incident & Complaint Processes; Conflict Resolution