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Case Resolution Specialist I
HMSA
Honolulu, UAE
Full Time
Entry
Hybrid
3 weeks ago
Appeals ManagementGrievance HandlingProblem SolvingCommunicationMicrosoft OfficeRegulatory Compliance
Free
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Appeals ManagementGrievance HandlingProblem Solving
About the Role
HMSA seeks a Case Resolution Specialist I to research and respond to member and provider appeals, complaints, and grievances. The role requires a bachelor's degree and one year of related experience, with hybrid work on Oahu.
Key Skills for This Role
Appeals ManagementGrievance HandlingProblem SolvingCommunicationMicrosoft OfficeRegulatory Compliance
Responsibilities
- Conduct critical analysis of highly complex and sensitive member and provider appeals, inquiries and grievances
- Secure information from internal and external resources to resolve issues
- Assist Supervisor and Coordinator in working as a liaison with providers, members and internal decision makers
- Negotiate/resolve sensitive issues with internal and external parties
- Present full explanation of member's or provider's position to management and decision makers
- Triage cases to resolve them upon initial inquiry
- Participate on cross departmental committees and other internal meetings
- Identify when changes to policies and procedures are needed
- Analyze and identify issues that may require multiple department efforts to resolve
- Assist with implementation of resulting decisions for change/resolution
- Assist supervisor/manager in responding to internal investigations, reviews, and audits
- Identify member problems, member education needs, or trends and report to manager
Requirements
- Bachelor's degree and one year of related work experience; or equivalent combination of education and related work experience
- Effective verbal and written communication skills
- Problem identification and resolution skills
- Basic knowledge of Microsoft Office applications including Word, Excel, Outlook, and PowerPoint
Full Job Posting
Job Summary
- Hybrid Work Environment Must reside on Oahu
- Pay Range: $42,000 $68,000
- Research and respond to member and provider appeals, complex complaints, grievances and inquiries relating to health plan coverage.
Minimum Qualifications
- Bachelor's degree and one year of related work experience; or equivalent combination of education and related work experience.
- Effective verbal and written communication skills
- Problem identification and resolution skills
- Basic knowledge of Microsoft Office applications including Word, Excel, Outlook, and PowerPoint.
Duties And Responsibilities
- Conducts critical analysis of highly complex and sensitive member and provider appeals, inquiries and grievances.
- 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.
- Negotiates/resolves sensitive issues with internal and external parties.
- Takes all facts and research from internal and external resources and presents a full explanation to management.
- Triages cases to resolve them upon initial inquiry.
- Participates on cross departmental committees and other internal meetings.
- Identifies when changes to policies and procedures are needed.
- Analyzes and identifies issues that may require multiple department efforts to resolve.
- Presents recommendations to internal committees, subgroups and executive management.
- Assists with the implementation of resulting decisions for change/resolution.
- Assists supervisor/manager in responding to internal investigations, reviews, and audits.
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