Case Resolution Specialist II

Job Summary

Hybrid Work Environment - Must reside on Oahu
Pay Range: $42,000 - $68,000
Note: Individuals typically begin between the minimum to middle of the pay range

Minimum Qualifications

• Bachelor's degree and two years 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 but not limited to Word, Excel, Outlook, and Power Point.

Duties And Responsibilities

• 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.
• Trairs 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 internal meetings to identify, clarify, research, and resolve inquiries and issues.
• Identifies when changes to policies and procedures are needed based on case resolutions, statutory or regulatory changes, or accreditation requirements.
• Proposes changes to management based on identification and analysis.
• Analyzes and identifies issues that may require multiple department efforts to resolve.
• Coordinates discussions and meetings to develop processes to resolve those issues.
• Presents recommendations to internal committees, subgroups and executive management for decision making purposes as it relates to cases.
• Aids in the implementation of resulting decisions for change/resolution.
• Aids supervisor/manager in responding to internal investigations, reviews, and audits; regulatory inquiries; and accreditation related audits.
• Aids internal customers with complex member/physician inquiries.
• Aids Supervisor and Coordinator with training.
• Identifies member problems, member education needs, or trends and report these to manager, as well as recommend resolution.
• Takes a proactive role in reviewing, digesting and communicating any new regulation, standard, business change, etc. affecting the member advocacy and/or appeals process.
• Aids in the coordination of changes among departments.
• Aids in determining internal and external impacts.
• Performs quality assurance of case documents and assists Supervisor and Manager with various corporate activities.
• Performs all other miscellaneous responsibilities and duties as assigned or directed.