Senior Resolution Specialist

University Health; San Antonio (TX); On-site; USD 52,000 - 76,000; Full time

Job summary

University Health is seeking a professional with comprehensive knowledge of Community First insurance products and experience in managed care to resolve member inquiries, complaints, and appeals. The role focuses on CMS and HICS-related submissions, regulatory communications, and timely issue resolution.

The candidate should have a bachelor's degree in business or health care and at least one year in managed care, with four years in health insurance or customer service; experience in

Qualifications

• Bachelor’s degree in business, health care or related field with at least one year of experience in the managed care industry.
• Minimum of four years’ experience in health insurance or customer service.
• Complaints and appeals resolution or quality improvement management experience preferred

Responsibilities

• Resolve member inquiries, complaints, and appeals related to insurance products.
• Acknowledge, investigate, and resolve inquiries to ensure timely review and resolution.
• Navigate third party software for member eligibility and payment status

Skills

Customer service

Regulatory/complaints handling

Problem solving

Education

Bachelor's degree in business, health care or related field

Tools

Health Insurance Casework System (HICS)

Job description

POSITION SUMMARY/RESPONSIBILITIES

Comprehensive knowledge in all Community First insurance products including STAR Medicaid, Children’s Health Insurance Plan (CHIP, CHIP Perinate, CHIP Perinatal, CHIP Perinatal Newborn, University Family Care Plan (UFCP),Marketplace (University Community Care Plans UCCP), Commercial, Medicare Advantage Alamo Plan HMO, Medicare D-SNP HMO to resolve member inquiries, complaints, and appeals. Specializes in Marketplace inquiries and complaints received through the Health Insurance Casework System (HICS) from Centers for Medicare & Medicaid Services (CMS), Authorities to Approve (AA), and correspondence received via member portal/website. This also includes responding to member or regulatory agencies when appropriate and assisting with member walk-ins. Ensures all member oral or written inquiries, complaints and appeals are acknowledged, investigated and resolved ensuring timely review and resolution to member and/or regulatory agency. Able to navigate and understand third party software utilized for member eligibility and payment status

EDUCATION/EXPERIENCE

Bachelor’s degree in business, health care or related field with at least one year of experience in the managed care industry is required. Minimum of four years’ experience in health insurance, or customer service industry can be substituted for education. . Complaints and appeals resolution or quality improvement management experience is also preferred