Supervisor, Escalation

Harbor Health•,

About The Position

The Supervisor of Escalation leads Harbor Health's complaint resolution function, overseeing a team of resolution specialists responsible for investigating member and provider grievances, appeals, and escalated issues. This role ensures resolution processes are consistent, compliant with HIPAA, CMS, TDI, and internal policy standards, and continuously improving. The Supervisor serves as the primary cross-functional liaison between the contact center, Legal, Compliance, Quality Assurance, and Operations.

Requirements

3+ years in healthcare contact center operations with a focus on escalations, grievances, or appeals
Thorough knowledge of health insurance operations: claims, enrollment/eligibility, billing, prior authorization, and provider networks
Expert understanding of HIPAA, CMS, TDI, and state/federal managed care compliance standards
Demonstrated experience with both member and provider services escalation processes
Ability to interpret EOBs, plan policy language, and contractual agreements to resolve member disputes
Strong team leadership, coaching, and performance management skills
Exceptional written and verbal communication; able to manage executive-level and high-stakes member communications
Proficiency in complaint tracking/CRM systems and reporting tools
Bachelor's degree preferred; equivalent work experience considered

Nice To Haves

Experience in a payvider, ACO, or value-based care environment
Lean, Six Sigma, or process improvement methodology certification
Familiarity with HEDIS, Star Ratings, and quality performance metrics
Bilingual: English / Spanish
Experience with Athena or similar EHR platforms
Prior experience in a startup or high-growth healthcare organization

Responsibilities

Direct and supervise team research and analysis of all incoming member and provider complaints to determine root causes and appropriate corrective actions
Develop, implement, and continuously refine resolution methodologies and SOPs for complex member issues, ensuring consistency and regulatory compliance
Maintain integrity of the complaint tracking system; ensure all complaint details, investigation steps, resolutions, and follow-up activities are rigorously documented
Ensure all complaint-handling procedures adhere to internal policies and applicable regulations (HIPAA, CMS, TDI, Medicare/Medicaid/Commercial plan standards)
Design and manage proactive member and stakeholder follow-up processes to confirm resolution satisfaction and mitigate issue recurrence
Generate and formally present comprehensive reports on complaint trends, resolution cycle times, and compliance metrics to senior leadership
Serve as primary cross-functional liaison with Legal, QA, and Operations to address systemic deficiencies identified through the complaints process
Act as final escalation point for highly complex or sensitive issues; provide expert guidance throughout the resolution lifecycle
Develop and oversee the contact center QA program, including call monitoring, transaction review, scoring calibration, and SOP maintenance
Coach, develop, and performance-manage resolution team members; drive process improvement using Lean, Six Sigma, or similar methodologies