Remote-Resolution Specialist

Alignment Health

19h•Remote

About The Position

Alignment Health is transforming healthcare by serving seniors and the chronically ill. The company is built on a team of passionate individuals dedicated to putting seniors first, offering ample room for growth and innovation. Working at Alignment Health provides an opportunity to make a significant impact on lives. The Resolution Specialist is responsible for managing and resolving complex member issues through proactive outreach, case ownership, and cross-functional coordination. This role acts as a frontline problem solver, addressing concerns related to authorizations, claims, benefits, provider access, and service experience accurately and compassionately within defined turnaround times. Resolution Specialists own cases from intake to closure, ensuring members feel heard and supported. Operating within a structured case management environment, this role aims to improve turnaround times, reduce aging inventory, and deliver a high-quality member experience in line with regulatory and organizational standards. The position is crucial to the Customer Resolution team's mission of delivering caring connections while identifying trends and improvement opportunities to enhance operational performance and prevent recurring issues.

Requirements

Minimum 1 year of healthcare experience.
Minimum 1 year of contact center experience involving complex problem solving, escalation handling, or issue resolution.
Experience assisting members with navigating healthcare services including referrals, authorizations, claims, or benefits.
Experience supporting Medicare Advantage or managed care members with benefits navigation including medical, prescription drug, or supplemental benefits.
High School Diploma or GED
Ability to clearly explain health plan coverage, benefits, and services to members.
Strong verbal and written communication skills with the ability to build trust and rapport with members and partners.
Effective problem-solving and analytical skills with the ability to investigate and resolve complex issues.
Strong organizational and time management skills to manage multiple active cases.
Ability to collaborate effectively with cross-functional teams and external partners.
Intermediate proficiency in Microsoft Office Suite (Outlook, Word, Excel).
Ability to read and interpret procedure manuals, policy documents, and operational guidelines.
Ability to apply sound judgment and reasoning when evaluating member issues and determining appropriate resolution.

Nice To Haves

3+ years healthcare experience.
Experience in grievance, escalation, or resolution-focused contact center environments.
Medicare Advantage or managed care experience.
College coursework in healthcare administration, business, or related field
Bilingual English and Spanish, Chinese (Mandarin or Cantonese), or Vietnamese.

Responsibilities

Manage assigned member resolution cases from intake through final closure, ensuring complete and timely resolution of member concerns.
Serve as a subject matter resource for escalated member issues including claims, authorizations, referrals, benefits clarification, provider network concerns, and access to care.
Conduct outbound outreach and handle inbound contacts to investigate, resolve, and communicate case outcomes within established turnaround time expectations.
Provide clear explanations of health plan benefits, coverage policies, services, and available resources to ensure members understand their options and next steps.
Demonstrate empathy, professionalism, and accountability while maintaining a “caring connection” mindset to fully resolve member issues whenever possible.
Support other customer experience teams including inbound as needed.
Maintain accurate and detailed case documentation in all required systems to support resolution tracking, regulatory compliance, and reporting.
Ensure timely case updates, proper categorization, and completion of required wrap-up activities to maintain data integrity.
Manage assigned caseload to support departmental goals for case closure rates, productivity, and aging inventory reduction.
Monitor case progress and proactively escalate barriers that may delay resolution.
Collaborate with internal departments including Operations, Clinical, Claims, Enrollment, Provider Relations, and Compliance to resolve complex member concerns.
Coordinate with external partners such as provider offices, supplemental benefit vendors, and interpreter services when required to facilitate member resolution.
Ensure member cases requiring multi-department engagement are tracked through completion and properly communicated to the member.
Ensure all resolution activities adhere to CMS, regulatory, and organizational compliance standards.
Deliver high-quality service that supports member satisfaction, retention, and service recovery.
Apply critical thinking and problem-solving skills to identify the root cause of member concerns and prevent repeat contacts when possible.
Identify recurring issues, barriers, or trends impacting member experience and share insights with leadership for process improvement.
Participate in quality reviews, coaching sessions, and performance discussions to strengthen resolution skills and service delivery.
Support team learning and development through knowledge sharing, peer support, and participation in training initiatives.
Assist with onboarding and mentoring of new hires through shadowing or knowledge transfer when requested.
Participate in team meetings, training sessions, and departmental initiatives.
Support organizational campaigns such as care gap outreach or benefit education when applicable.
Perform other duties as assigned to support team objectives and member service goals.