HMSA
Role Overview
Case Resolution Specialist I
at HMSA – Full‑time, Exempt
Job Summary Research and respond to member and provider appeals, complex complaints, grievances and inquiries relating to all aspects of health plan coverage consistent with contract, regulatory and/or accreditation requirements. Seeks management guidance and supervisor/manager direction as needed.
Employment Type Full‑time | Exempt
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 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 (Word, Excel, Outlook, PowerPoint).
Duties and Responsibilities
Conduct critical analysis of highly complex and sensitive member and provider appeals, inquiries and grievances and apply internal policies and procedures, contractual provisions, and regulatory requirements.
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 to represent HMSA objectives, goals, and expectations for meeting contractual, regulatory, and accreditation requirements.
Negotiate and resolve 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.
Triage cases to resolve them upon initial inquiry to best serve the member and minimize the number of cases escalated to senior management and executives.
Participate, at the direction and supervision of management, on cross departmental committees and other internal meetings to identify, clarify, research, and resolve inquiries and issues.
Identify when changes to policies and procedures are needed based on case resolutions or regulatory changes.
Propose changes to management based on analysis.
Analyze and identify issues that may require multiple department efforts to resolve.
Present recommendations to internal committees, subgroups and executive management for decision making purposes after discussion and approval from Supervisor and Coordinator.
Assist supervisor/manager in responding to internal investigations, reviews, audits, regulatory inquiries and accreditation related audits.
Assist internal customers with complex member/physician inquiries with guidance and direction from management.
Identify member problems, member education needs or trends and report to manager and recommend resolution.
Take proactive role in reviewing, digesting and communicating new regulations, standards, business changes affecting member advocacy or appeals process. At direction of management, assist in coordinating changes among departments.
Perform quality assurance of case documents and assist Supervisor and Manager with various corporate activities.
Perform all other miscellaneous responsibilities and duties as assigned or directed.
Additional Information Referrals increase your chances of interviewing at HMSA by 2x.
Get notified about new Case Specialist jobs in Honolulu, HI.
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at HMSA – Full‑time, Exempt
Job Summary Research and respond to member and provider appeals, complex complaints, grievances and inquiries relating to all aspects of health plan coverage consistent with contract, regulatory and/or accreditation requirements. Seeks management guidance and supervisor/manager direction as needed.
Employment Type Full‑time | Exempt
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 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 (Word, Excel, Outlook, PowerPoint).
Duties and Responsibilities
Conduct critical analysis of highly complex and sensitive member and provider appeals, inquiries and grievances and apply internal policies and procedures, contractual provisions, and regulatory requirements.
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 to represent HMSA objectives, goals, and expectations for meeting contractual, regulatory, and accreditation requirements.
Negotiate and resolve 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.
Triage cases to resolve them upon initial inquiry to best serve the member and minimize the number of cases escalated to senior management and executives.
Participate, at the direction and supervision of management, on cross departmental committees and other internal meetings to identify, clarify, research, and resolve inquiries and issues.
Identify when changes to policies and procedures are needed based on case resolutions or regulatory changes.
Propose changes to management based on analysis.
Analyze and identify issues that may require multiple department efforts to resolve.
Present recommendations to internal committees, subgroups and executive management for decision making purposes after discussion and approval from Supervisor and Coordinator.
Assist supervisor/manager in responding to internal investigations, reviews, audits, regulatory inquiries and accreditation related audits.
Assist internal customers with complex member/physician inquiries with guidance and direction from management.
Identify member problems, member education needs or trends and report to manager and recommend resolution.
Take proactive role in reviewing, digesting and communicating new regulations, standards, business changes affecting member advocacy or appeals process. At direction of management, assist in coordinating changes among departments.
Perform quality assurance of case documents and assist Supervisor and Manager with various corporate activities.
Perform all other miscellaneous responsibilities and duties as assigned or directed.
Additional Information Referrals increase your chances of interviewing at HMSA by 2x.
Get notified about new Case Specialist jobs in Honolulu, HI.
#J-18808-Ljbffr