Case Resolution Specialist I

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. - 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. - At the direction and supervision of management, participates on cross departmental committees and other internal meetings to identify, clarify, research, and resolve inquiries and issues. - Identifies when changes to policies and procedu...