Case Resolution Specialist II

HMSA•Honolulu, HI

About The Position

This role involves conducting critical analysis of complex and sensitive member and provider appeals, inquiries, and grievances. The specialist will apply internal policies, contractual provisions, and regulatory requirements to resolve issues. This includes securing information from various resources, acting as a liaison between providers, members, and internal decision-makers, and negotiating sensitive issues. The specialist will also present findings to management, triage cases to minimize escalations, and participate in cross-departmental committees to identify and resolve issues. This role requires identifying the need for policy changes, proposing these changes, and assisting in their implementation. Additionally, the specialist will support supervisors and managers with internal investigations, audits, regulatory inquiries, and training. A proactive approach to understanding and communicating new regulations and business changes affecting the appeals process is expected. Quality assurance of case documents and assistance with corporate activities are also part of the responsibilities. The role may also involve performing other miscellaneous duties as assigned.

Requirements

Bachelor's degree and two years 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.

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.
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.