Member Advocacy & Appeals Support Specialist II

HMSA; United States; Remote; USD 42,000 - 78,000; Full time

Job summary

HMSA in Honolulu seeks an Administrative Support Specialist to provide high-level support to the Member Advocacy and Appeals department. This full-time, non-exempt role handles intake, case creation, and confidential communications.

You will manage calls, faxes, and emails, maintain electronic case files, and ensure timely processing in accordance with policy and regulatory requirements.

Qualifications

• Diploma and one year of related experience or an equivalent combination of education and related work experience.
• Strong verbal and written communication skills.
• Basic working knowledge of Microsoft Office applications including Word, Excel, and Outlook.

Responsibilities

• Handles intake for department cases with complex confidential issues in a time-sensitive environment.
• Intake of member/provider calls, faxes, emails, and referrals; evaluate information for best action; coordinate with departments to ensure timely case creation.
• Analyze sensitive member and provider appeals, inquiries and grievances per internal policies and regulatory requirements.
• Triage cases to resolve at initial inquiry to best service members and reduce escalations.
• Create and maintain accurate electronic case files for appeals and grievances within policy and regulatory timeframes.
• Identify potential issues in case files and discuss with supervisor or coordinator.
• Update electronic case folders and program database entries.
• Handle internal and external customer service calls regarding appeals or grievance requests.
• Assess callers' needs and communicate professionally to ensure excellent service.
• Perform other duties as assigned.

Skills

Verbal communication

Written communication

Microsoft Office

Education

Diploma or equivalent

Tools

Microsoft Word

Microsoft Excel

Microsoft Outlook

Job description

Remote

Employment Type

Full-time

Exempt or Non-Exempt

Non-exempt [Non-ex.]

Job Summary

Worksite Location (In-Office): Honolulu

Pay Range: $42,000 - $78,000

Note: Individuals typically begin between the minimum to middle of the pay range

Provides high level administrative and clerical support to Member Advocacy and Appeals department.

Minimum Qualifications

• Diploma and one year of related experience; or an equivalent combination of education and related work experience.
• Strong verbal and written communication skills
• Basic working knowledge of Microsoft Office applications including Word, Excel, and Outlook.

Duties and Responsibilities

• Handles the intake processes for all Department cases that involve complex confidential issues in a highly time sensitive environment.
• Intake of member and provider calls, faxes, email correspondence, and internal referrals; evaluation of information to determine best course of action; and follow-up with Department staff and internal departments to ensure accurate case creation are completed consistent with information relayed to members/providers and within timeframe required by law, regulation, policy, or other requirement.
• Conduct analysis of sensitive member and provider appeals, inquiries and grievances and applies internal policies and procedures, contractual provisions, and regulatory requirements.
• Triage cases to resolve them upon initial inquiry/intake to best service members and reduce cases escalated to Case Resolution Specialists.
• Creates and maintains accurate electronic case files for appeals and grievances from members and providers within the scope of internal policies and procedures, and regulatory timeframe requirements.;.
• Identifies potential issues when preparing and reviewing electronic cases including case file and program database entry and discusses these with the department supervisor or coordinator.
• Updates electronic case folder and computer program database.
• Handles internal and external customer service calls regarding member or provider appeals or grievance requests.
• Is able to handle complex issues and requests by listening for understanding and communicates appropriately and professionally with internal/external customers.
• Is able to identify what the caller is requesting, and asks questions for understanding, to offer excellent customer service experience.
• Performs all other miscellaneous responsibilities and duties as assigned or directed.