Escalation Specialist

Harbor Health•,

About The Position

The Contact Center Escalation Specialist is responsible for investigating, documenting, and resolving complex member and provider complaints within Harbor Health's contact center. This role requires strong analytical skills, deep knowledge of health insurance processes, and a commitment to delivering thorough, compliant resolutions. The Escalation Specialist collaborates closely with Legal, QA, and Operations teams to address systemic issues and ensure outstanding member outcomes.

Requirements

1–2 years of experience in member services or provider services within a healthcare environment
Comprehensive understanding of health insurance plan processes: claims, appeals, grievances, and prior authorizations
Proficiency in healthcare compliance standards and internal policies related to complaint management (HIPAA, CMS, TDI)
Proven experience with compliance procedures and medical group plan operations
Exceptional written and verbal communication; ability to manage sensitive member issues with professionalism
Strong research, analysis, and problem-solving skills to identify root causes and implement effective resolutions
Competency maintaining records in CRM or complaint management software
Ability to collaborate effectively with Legal, QA, and Operations teams

Nice To Haves

Prior experience in a primary care or value-based care setting
Familiarity with payvider, ACO, or managed Medicaid/Medicare environments
Experience with Athena or similar EHR/practice management systems
Bilingual: English / Spanish
Understanding of HEDIS or Star Ratings quality measures

Responsibilities

Conduct research and analysis of incoming member and provider complaints to determine root causes and appropriate corrective actions
Implement resolution strategies for complex member issues, ensuring consistent and compliant outcomes in line with Harbor Health policies and regulatory requirements
Document all complaint details, investigation steps, resolutions, and follow-up activities with meticulous accuracy in the designated tracking system
Ensure complaint handling procedures and resolutions adhere to internal policies and applicable regulations (HIPAA, CMS, TDI)
Execute timely, proactive follow-up with members and internal stakeholders to confirm resolution satisfaction and mitigate recurrence or further escalation
Collaborate cross-functionally with Legal, Quality Assurance, and Operations to address systemic issues identified through the complaints process