Job Summary:
In addition to the responsibilities listed below, this position also coordinates and monitors 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 documentationis prepared for decision making processes; leveraging a comprehensive foundational knowledgeof the product/service domain to contribute to satisfactory resolutions of moderately complex 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 and leaders in order to resolve member challenges; recognizing service gaps that contribute to dissatisfaction among customers, members, key stakeholders and/or functional areas with minimal guidance; Making decisions on appropriate case types using their own 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 proactively providing resources, information, advice, and expertise with coworkers and members. Listens to, seeks, and addresses performance feedback; provides mentoring to team members. Pursues self-development; creates plans and takes action to capitalize on strengths and develop weaknesses; influences others through technical explanations and examples. Adapts to and learns from change, challenges, and feedback; demonstrates flexibility in approaches to work; helps others adapt to new tasks and processes. Supports and responds to the needs of others to support a business outcome.

Completes work assignments autonomously by applying up-to-date expertise in subject area to generate creative solutions; ensures all procedures and policies are followed; leverages an understanding of data and resources to support projects or initiatives. Collaborates cross-functionally to solve business problems; escalates issues or risks as appropriate; communicates progress and information. Supports, identifies, and monitors priorities, deadlines, and expectations. Identifies, speaks up, and implements ways to address improvement opportunities for team.

Performs member, customer, or employee incident case management by: monitoring and analyzing the case tracking database to identify moderately complex, specialty, or flagged cases that require resolution as well as reporting trends to management; processing moderately complex and specialty/flagged incident cases; and ensuring compliance of own work with internal and external rules in the performance of case management activities with some review necessary.

Performs member or employee incident case research by: investigating claims, authorizations, member contracts, and/or customer service interactions across members and customers to make determinations for moderately complex and specialty or flagged incident cases.

Resolves member or employee incident cases by: making decisions regarding moderately complex or specialty/flagged incident cases through interacting with business leaders and other stakeholders; and resolving moderately complex or specialty/flagged cases and implementing case decisions.

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

Performs case documentation by: maintaining confidentiality of member, customer, or employee information throughout numerous documentation activities for moderately complex or specialty/flagged cases; and documenting moderately complex or specialty/flagged cases in accordance with all internal and external requirements.

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 AND minimum two (2) years of experience in health care, health insurance, sales and marketing, or a directly related field OR Minimum five (5) 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