Remote Bilingual Spanish Resolution Specialist

Alignment Health•Remote CA Outside Bay Area, CA

4d•$41,600 - $57,600•Remote

About The Position

The Resolutions Specialist provides member issue resolution by managing and resolving healthcare insurance claims in a timely and accurate manner. The role requires analytical skills, knowledge of healthcare insurance policies, and a commitment to service for policyholders, healthcare providers, and internal stakeholders. The bilingual Spanish Resolution Specialist joins the member engagement team to intake complex member cases and provide prompt, satisfactory resolutions. The role aims to decrease turnaround time, improve resolution quality, manage barriers to resolution, and contribute to process improvement and Voice of the Customer (VoC) efforts. The schedule is Monday through Friday, with working hours assigned within the listed time ranges for Pacific, Mountain, Central, or Eastern Time zones. The specialist must be available to work full-time and overtime during the Annual Enrollment Period (October through December) and Open Enrollment Period (January through March). Time off is not permitted during the first five weeks of training or during January.

Requirements

At least one year of healthcare experience and/or training is stated; the posting also states that 3–4 years of healthcare experience/training is required.
At least one year of outbound call center experience, which may include welcome/onboarding, appointment scheduling, retention, sales, or other healthcare or health-plan programs; and/or inbound call center experience involving a higher level of problem-solving, such as escalation or resolution.
Experience helping members navigate access to care through Medicare Advantage or HMO plans, including referrals and authorizations.
Experience helping members navigate Medicare Advantage benefits, including medical, prescription drug, and supplemental benefits.
High school diploma or GED, or an equivalent combination of education and experience.
Intermediate proficiency in Microsoft Office Suite, including Outlook, Word, and Excel.
Bilingual ability in English and Spanish, Chinese (Mandarin or Cantonese), or Vietnamese.
Ability to work independently, stay motivated, prioritize assignments, and maintain productivity.
Ability to work as a team member and support colleagues in reaching organizational goals.
Ability to learn, describe, explain, and educate members about health plan coverage and services.
Passion for customer service and member retention; excellent customer service skills and comfort speaking on the phone.
Ability to troubleshoot and solve problems.
Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals.
Ability to write routine reports and correspondence and speak effectively before groups of customers or employees.
Ability to perform basic arithmetic with two-digit numbers and multiply and divide with tens and hundreds, including calculations using American units of money, weight, volume, and distance.
Ability to use common-sense understanding to follow detailed but uncomplicated written or oral instructions and handle problems involving a few concrete variables in standardized situations.
Availability to work full-time and overtime during the Annual Enrollment Period (October through December) and Open Enrollment Period (January through March).

Responsibilities

Serve as a subject matter expert on escalated member calls involving authorizations, claims, and provider network issues, and resolve escalations based on knowledge of healthcare processes and protocols.
Identify process improvement opportunities within the member engagement department through collaboration with other departments.
Maintain knowledge of procedures, protocols, benefits, services, and other information needed to resolve member issues and inquiries.
Conduct outbound calls and receive inbound calls within department timeframes, honoring member communication preferences when possible, including time of day, channel, and language; use multilingual skills or interpreter services as needed.
Collaborate with other departments, supplemental benefit vendors, and the provider network to facilitate the member experience.
Identify members targeted for care gaps and other campaigns, connect them with appropriate programs or services, analyze program eligibility, and refer eligible members to providers or vendors.
Document interactions in real time and complete timely wrap-up in all systems and applications, accurately entering member demographics and other information to support outcomes reporting and data integrity.
Meet and exceed individual and team goals, submit activity reports in the required format and frequency, provide excellent customer service, and promote member satisfaction.
Participate in required team meetings and trainings and demonstrate satisfactory understanding of new information and processes.
Adhere to attendance and productivity policies.
Assist with developing and training new hires, including shadowing and nesting.