Customer Advocacy Specialist I

About the role

As a Customer Advocacy Specialist at Wellmark, you will be the trusted voice for our members. In this role, you’ll advocate on behalf of customers by coordinating, researching, and resolving complaints, live escalations, and service experience or disruption reviews in alignment with state, federal, and Wellmark guidelines. You will communicate resolutions directly to customers with clarity and empathy, while also helping them understand their products, benefits, and the tools available to support them.

Success in this role comes from your ability to look beyond the issue at hand. You will partner with business areas across the organization to address concerns and deliver timely, accurate solutions, while also providing valuable feedback on how complaints and inquiries are handled. Your insights will help identify opportunities to improve the overall service experience, ensuring that members feel supported and confident in the care and resources they receive. This is more than a problem-solving position—it’s a chance to make a meaningful impact on the customer journey by serving as both an advocate and an educator, strengthening relationships with our members and influencing improvements in how we deliver service.

Responsibilities

• Coordinate, research, and resolve customer complaints, including live escalations and service experience and disruption reviews.
• Advocate for the customer, seek to understand complaints, and provide education when appropriate.
• Review and analyze customer feedback and data, including processes across the company where customers may experience disruption, and identify and recommend areas for improvement.
• Ensure customer complaint resolution within appropriate timeframes set forth by corporate and governmental guidelines.
• Communicate (typically via phone and/or written letter) and confirm resolution with the customer, ensuring they are educated and understand their products, benefits, tools, and how to use them.
• Adjust and process claims as needed to complete resolution of customer complaints, with partnership from Customer Advocacy Specialist II.
• Ensure all documentation regarding complaints is thorough and routed to the appropriate support areas for further investigation and resolution.
• Draft a variety of written communications regarding complaint updates, education, and resolution.
• Develop and maintain team member relationships through positive interactions.
• Partner and collaborate with other business areas, such as Appeals, Legal, Compliance, Health Services, Network Engagement, and Sales to ensure appropriate complaint resolution.
• Provide feedback to Customer Service team leaders and other areas of the business regarding complaints, escalations, and service experience & disruption.
• Provide complaint reports to various business areas (e.g., complaint reports for account teams or claim summary reports) for trend analysis.
• Maintain knowledge of healthcare guidelines and policies, contracts, standard operating procedures, and other Federal regulations as well as Corporate and Departmental guidelines affecting the complaint process.
• Perform outreach calls to members and providers relating to health benefits, claims processing/payment, and other complaints.
• Identify and make recommendations for training and educational opportunities for Wellmark internal staff, including but not limited to Knowledge Article updates, Voice of the Customer, or huddle announcements.
• Identify and make recommendations for process improvement through research and analysis, and proactively provide possible solution recommendations.
• Provide backup support as needed to HICS case processing.
• Other duties as assigned.

Requirements

• High School Diploma or GED.
• 3+ years of experience in health insurance operations OR 4+ years of experience handling customer complaints/inquiries in a highly regulated industry.
• Understanding and/or application of relevant regulations and business rules required to perform the role.
• Travel required up to 5%.

Skills

• Excellent verbal and written communication skills; develops and maintains strong relationships with clients (Wellmark members/groups, internal stakeholders, and external stakeholders) by listening to the client/customer and understanding and responding to identified needs.
• Strong de-escalation skills; effectively resolves issues and conflicts in a professional manner while maintaining composure and confidence. Displays empathy and discerns stakeholders’ true intent.
• Exceptional organization skills, time management, and attention to detail.
• Strong business knowledge and perspective; ability to synthesize complex information and develop theories to arrive at logical recommendations.
• Experience compiling and analyzing data for the purpose of telling a story with the data/metrics.
• Ability to research and use appropriate interaction skills and methods to guide individuals or groups to accomplish work, reach consensus, or take action.
• Ability to measure and evaluate work processes, and utilize appropriate resources to identify next steps, potential impacts/risks, and solutions.
• Knowledge of electronic systems such as Microsoft applications, email, internet, and other online tools.

Qualifications

• Preferred: Associate’s degree.