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Healthcare Case Resolution Specialist
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Healthcare Case Resolution Specialist

Job Description

We are seeking a Healthcare Case Resolution Specialist for a very important client.

Job Description:

Receives responds, resolves & documents written & electronic member correspondence & performs service recovery to include member, regulatory & senior leadership complaints in accordance w/ applicable regulatory requirements, external laws & accreditation standards. Makes members/patients & their needs a primary focus of one's actions; develops & sustains productive member/patient relationships. Actively seeks information to understand member/patient circumstances, problems, expectations & needs. Builds rapport & cooperative relationships w/ member/patients. Considers how actions or plans will affect member; responds quickly to meet member/patient needs & resolves problems. Accountable for creating a culture of compliance, ethics & integrity. Maintains knowledge of & assures departmental compliance w/ company's Principles of Responsibility & policies & procedures, & applicable regulatory requirements & accreditation standards. Responds appropriately to observed fraud or abuse.

Top 3 - 5 Daily Responsibilities

- Receives, responds, resolves & documents formal written & electronic member correspondence to include, member, regulatory & senior leadership complaints in accordance w/ applicable regulatory requirements, external laws & accreditation standards

- Develops & maintains contact w/ key individuals in research & resolution of complaints to insure timeliness of resolution of the provider/patient relationship

- Provides appropriate financial services recovery up to $1,000 w/ additional amounts as authorized by member services leadership

- Researches, confirms & issues benefit payment & medical necessity adverse determinations (denials)

- Issues denials

- Responds to fraud/abuse allegations committed by members evaluate, document, investigate, legitimize & determine appropriate plan of action, potentially resulting in terminating the member & their family(s) health insurance w/ company

Job Requirements

The ideal candidate will need the following:

-Dynamic Strong Communication skills both interpersonal and written. Candidate must have very strong ability to communicate in person in addition to a strong resume. Proven Customer

-Service Skills while working under pressure with company Members a top priority!!

-Any Clinical Background very appreciated.

-Manager looking for any of the following Coding, Billing, Pharmaceutical, & Legal Background in Healthcare, or Insurance Experience very appreciated.

-Candidates must have proven ability to deal with difficult customers on the phone. Candidates will be dealing with frustrated members 80% of the time on the phone and the goal will be to have that company Member have there challenging issue resolved.

Top 3 - 5 Required Skills

Two years’ experience in any of the following areas:

-responding to member benefit, or billing inquiries;

-responding to Case Resolution quality issues or complaints.

- Demonstrated experience w/ multiple computer applications

- Previous experience working w/ all levels of management/providers

Desired skills

- 2-4 years’ experience in health care quality/ complaint management

- Experience w/ regulatory & member fraud abuse

Soft Skills

- Demonstrated effective interpersonal verbal & written communication skills

Job Snapshot

Employment Type Contractor
Job Type Admin - Clerical
Education Not Specified
Experience Not Specified
Manages Others Not Specified
Relocation No
Industry Healthcare - Health Services, Other Great Industries
Required Travel Not Specified
Job ID vkATR99252
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Healthcare Case Resolution Specialist


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