Case Resolution Specialist I

HMSA; Honolulu (HI); Hybrid; USD 42,000 - 68,000; Full time

Job summary

HMSA in Hawaii seeks a full-time Exempt position to research and respond to member and provider appeals, complex complaints, grievances and inquiries related to health plan coverage. The role requires guidance from supervision as needed and offers a hybrid work environment with residence on Oahu.

The incumbent handles critical analysis, coordinates with internal teams, and ensures alignment with contracts and regulatory requirements. Salary ranges from $42,000 to $68,000 depending on experience.

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, including Word, Excel, Outlook, and PowerPoint.

Responsibilities

• Conducts complex analysis of member and provider appeals, inquiries and grievances and applies internal policies, contractual provisions, and regulatory requirements.
• Secures information from internal and external resources to resolve issues.
• Acts as liaison with providers, members and internal decision makers to meet contractual, regulatory, and accreditation requirements.
• Negotiates/resolves sensitive issues with internal and external parties.
• Provides full explanations of positions and concerns to management and decision makers.
• Triages cases to resolve them on initial inquiry and minimize escalations.
• Participates on cross departmental committees to identify and resolve inquiries and issues.
• Identifies changes to policies and procedures based on resolutions, regulatory changes, or accreditation requirements.
• Proposes changes to management and presents recommendations for decision making.
• Assists with implementing decisions for change/resolution.
• Assists in responding to audits, regulatory inquiries, and accreditation-related audits.
• Assists internal customers with complex member/physician inquiries under guidance from management.
• Reports trends and member education needs to management and coordinates changes across departments.
• Performs quality assurance of case documents and supports corporate activities.
• Performs other duties as assigned.

Skills

Verbal communication

Written communication

Problem solving

Education

Bachelor's degree

Tools

Microsoft Word

Microsoft Excel

Microsoft Outlook

Microsoft PowerPoint

Job description

Hybrid Work Environment - Must reside on Oahu

Employment Type

Full-time

Exempt or Non-Exempt

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.

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. 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.
  • 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 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.
  • Presents recommendations to internal committees, subgroups and executive management for decision making purposes as it relates to cases after discussion and approval from Supervisor and Coordinator.
  • Assists with the implementation of resulting decisions for change/resolution.
  • Assists supervisor/manager in responding to internal investigations, reviews, and audits; regulatory inquiries; and accreditation related audits.
  • Assist internal customers with complex member/physician inquiries with guidance and direction from management.
• Identifies member problems, member education needs, or trends and reports 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. At direction of management, assists in the coordination of changes among departments.
• 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.