Senior Resolution Specialist

University Health; San Antonio (TX); On-site; USD 42,000 - 62,000; Full time

Job summary

University Health in Texas seeks an experienced insurance casework specialist to manage inquiries, complaints and appeals across Community First products including STAR Medicaid and CHIP variants. You will resolve issues via the Health Insurance Casework System (HICS) and coordinate with CMS authorities when needed.

The role requires building knowledge of eligibility and payment status through third-party software, ensuring timely, accurate responses to member inquiries and regulatory

Qualifications

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

Responsibilities

• Resolve member inquiries, complaints and appeals across Community First insurance products.
• Acknowledge and investigate inquiries ensuring timely resolution to member/regulatory agencies.
• Navigate third-party software for member eligibility and payment status and assist with walk-ins.

Skills

Customer service

Regulatory inquiries

Complaint resolution

CMS knowledge

Education

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

Tools

Eligibility software

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