Case Resolution Specialist II

Job description

- 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. - Functions 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. - Negotiates fees on behalf of members for non-covered or nonparticipating provider services in addition to soliciting claims and other related medical information from providers in order to resolve member inquiries. - 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. - Participates on cross departmental committees and other...