Alignment Healthcare USA, LLC
Resolution Specialist (Finance)
The Resolution Unit Representative I is a role within our Member Experience service teams focused on member issue resolution. As a Resolution Unit Representative, you will intake complex member cases and provide prompt and satisfactory resolution. This unit is dedicated to decreasing turnaround time, improving the quality of resolution, and managing barriers to resolution as part of process improvement and Voice of the Customer (VoC).
General Duties/Responsibilities (May include but are not limited to):
1. Serve as a "subject matter expert" in escalated member calls (i.e. authorizations, claims, provider network issues) and be able to resolve these escalations based on level of understanding/experience of healthcare, processes and protocols
2. Identify process improvement opportunities within the Member Engagement department given the collaboration with different departments
3. Be knowledgeable in procedures, protocols, benefits, services, and any other necessary information to resolve member issues and inquiries
4. Responsible for conducting outbound phone calls and/or receiving inbound phone calls within the department's goal timeframe; successfully contact and manage to the member's communication preferences as possible, which may include time of day, channel, and language; multi-lingual skills and/or utilize interpreter service as needed
5. Collaborate with our partners - including but not limited to other departments, supplemental benefit vendors, and provider network - to facilitate the member experience
6. Identify members targeted for care gaps and other campaigns, and connect members to programs or services when appropriate; analyze available programs, determine program eligibility, and connect member to appropriate provider or vendor
7. Responsible for real-time documentation and timely wrap-up to support outcomes reporting in all systems/applications as required; must enter member demographics and information with accuracy and attention to detail, i.e. feel responsible for the quality of our organizational data
8. Responsible for meeting or exceeding individual and team goals, and for submitting activity reports in the format and frequency required
9. Excel in customer service and contribute to a culture of going "above and beyond" to ensure the highest level of member satisfaction
10. Must participate in all required team meetings and trainings, and exhibit satisfactory understanding of new information and process
11. Adhere to all applicable attendance and productivity policies
12. Assist with the development and training of new hires including shadowing and nesting
13. Support other projects and duties as assigned by Management
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
14. Minimum Experience:
a. Minimum of 1-2 years healthcare experience and/or training required; 3-4 years of healthcare experience/training preferred
b. Excellent customer service and comfortable being on phones
c. Computer Skills: Intermediate MS Suite knowledge and experience
d. Ability to troubleshoot/problem solve
i. Language Skills: Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of the organization.
ii. Mathematical Skills: Ability to add and subtract two-digit numbers and to multiply and divide with 10's and 100's. Ability to perform these operations using units of American money and weight measurement, volume, and distance.
iii. Reasoning Skills: Ability to apply common sense understanding to carry out detailed, but un-involved written or oral instructions. Ability to deal with problems involving a few concrete variables in standardized situations.
e. Must be available to work full-time and over-time through the Annual Enrollment Period (Oct-Dec) and Open Enrollment Period (Jan-Mar)
15. Education and/or Experience:
a. High school diploma or general education degree (GED); or equivalent combination of education and experience.
a. Outbound call center experience which may include welcome/onboarding, appointment scheduling, retention, sales, or other health care/health plan related programs; and/or inbound call center experience that indicates a higher level of problem-solving such as escalation or resolution
b. Bilingual: English/Spanish, or Vietnamese, Chinese (Mandarin), Korean
c. Experience helping members navigate access to care through Medicare Advantage or HMO, including referrals and authorizations
d. Experience helping members navigate their Medicare Advantage benefits including medical, prescription drug, and supplemental benefits
e. Independently motivated self-starter who can prioritize work assignments and make every day a productive day
f. Team player willing to help and support colleagues, and do their part to support us all reaching our organizational goals
g. Natural "teacher" with the ability to learn plans and describe/explain/educate healthcare coverage and services to our members
h. Genuine passion for customer service and member retention
17. Work Environment
a. The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Essential Physical Functions:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
18. While performing the duties of this job, the employee is regularly required to talk or hear. The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
19. The employee frequently lifts and/or moves up to 10 pounds. Specific vision abilities required by this job include close vision and the ability to adjust focus.
Alignment Healthcare, LLC is proud to practice Equal Employment Opportunity and Affirmative Action. We are looking for diversity in qualified candidates for employment: Minority/Female/Disable/Protected Veteran.
If you require any reasonable accommodation under the Americans with Disabilities Act (ADA) in completing the online application, interviewing, completing any pre-employment testing or otherwise participating in the employee selection process, please contact firstname.lastname@example.org .