Customer Advocacy Specialist I

Wellmark, Inc.•Des Moines, IA

1d•Hybrid

About The Position

As a Customer Advocacy Specialist at Wellmark, you will be the trusted voice for our members. In this role, you’ll advocate on behalf of customers by coordinating, researching, and resolving complaints, live escalations, and service experience or disruption reviews in alignment with state, federal, and Wellmark guidelines. You will communicate resolutions directly to customers with clarity and empathy, while also helping them understand their products, benefits, and the tools available to support them. Success in this role comes from your ability to look beyond the issue at hand. You will partner with business areas across the organization to address concerns and deliver timely, accurate solutions, while also providing valuable feedback on how complaints and inquiries are handled. Your insights will help identify opportunities to improve the overall service experience, ensuring that members feel supported and confident in the care and resources they receive. This is more than a problem-solving position — it’s a chance to make a meaningful impact on the customer journey. By serving as both an advocate and an educator, you will help strengthen relationships with our members and influence improvements that shape the way we deliver service at Wellmark.

Requirements

High School Diploma or GED
3+ years of experience in health insurance operations OR 4+ years of experience handling customer complaints/inquiries in a highly regulated industry
Understanding and/or application of relevant regulations and business rules required to perform the role
Excellent verbal and written communication skills; develops and maintains strong relationships with clients (Wellmark members/ groups, internal stakeholders and external stakeholders) by listening to the client/customer and understanding and responding to identified needs
Strong de-escalation skills; effectively resolves issues and conflicts in a professional manner while maintaining composure and confidence. Displays empathy and discerns stakeholders’ true intent
Exceptional organization skills, time management and attention to detail
Strong business knowledge and perspective; ability to synthesize complex information and develop theories to arrive at logical recommendations
Experience compiling and analyzing data for the purpose of telling a story with the data/metrics
Ability to research and use appropriate interaction skills and methods to guide individuals or groups to accomplish work, reach consensus, or take action
Ability to measure and evaluate work processes, and utilize appropriate resources to identify next steps, potential impacts/risks, and solutions
Knowledge of electronic systems such as Microsoft applications, email, internet and other on-line tools
Travel required up to 5%

Nice To Haves

Associate’s degree

Responsibilities

Coordinate, research and resolve customer complaints, including live escalations and service experience and disruption reviews.
Be an advocate for the customer and seek to understand customer complaints and provide education when appropriate.
Review and analyze customer feedback and data, including processes across the company where customers have a chance to experience disruption, and identify and recommend areas for improvement.
Ensure customer complaint resolution within appropriate timeframes set forth by corporate and governmental guidelines.
Communicate (typically via phone and/or written letter) and confirm resolution with the customer and ensure customers are educated and understand their products, benefits, tools and how to use them.
As needed, adjust and process claims to complete resolution of customer complaints with Customer Advocacy Specialist II partnership.
Ensure all documentation regarding complaints are thorough and routed to the appropriate support areas for further investigation and resolution.
May draft a variety of written communications regarding complaint updates, education and resolution.
Successfully develop and maintain team member relationships through positive interactions.
Will partner and collaborate with other business areas, such as Appeals, Legal, Compliance, Health Services, Network Engagement and Sales to ensure appropriate complaint resolution.
Provide feedback to Customer Service team leaders and other areas of the business regarding complaints, escalations and service experience & disruption.
As needed, provide complaint reports to various business areas (i.e., complaint reports for account team or claim summary reports) for trend analysis.
Maintain knowledge of healthcare guidelines and policies, contracts, standard operating procedures, and other Federal regulations as well as Corporate and Departmental guidelines affecting the complaint process.
Perform outreach calls to members and providers relating to health benefits, claims processing/payment and other complaints.
Identify and make recommendations for training and educational opportunities for Wellmark internal staff, including but not limited to Knowledge Article updates, Voice of the Customer or huddle announcements, etc.
Identify and make recommendations for process improvement through research and analysis and proactively provide possible solution recommendations.
Provide back up support as needed to HICS case processing.
Other duties as assigned.