Case Resolution Specialist II
HMSA, Honolulu, HI, United States
Duration: Full Time
- 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.
- Functions 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.
- Negotiates fees on behalf of members for non-covered or nonparticipating provider services in addition to soliciting claims and other related medical information from providers in order to resolve member inquiries.
- 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.
- 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.
- Coordinates discussions and meetings to develop processes to resolve those issues.
- Presents recommendations to internal committees, subgroups and executive management for decision making purposes as it relates to cases.
- 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.
- Assists Supervisor and Coordinator with training.
- Identifies member problems, member education needs, or trends and report 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. Assists in the coordination of changes among departments. Assists in determining internal and external impacts.
- 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.