Position Summary The Resolution Specialist is responsible for managing escalated member and client concerns, ensuring timely and effective resolution of complex issues. This role operates within a fast-paced remote environment and serves as a key escalation point for high-touch situations requiring advanced communication, critical thinking, and cross-functional coordination. The Resolution Specialist ensures a positive member and client experience by maintaining professionalism under pressure, demonstrating strong ownership of issues, and facilitating solutions across internal teams. Responsibilities - Manage and resolve escalated member and client issues with urgency and professionalism. - Assess complex situations quickly and take prompt, independent action to drive resolution. - Maintain ownership of escalated cases from intake through resolution, ensuring follow-through and closure. - Communicate clearly and effectively with members, clients, and internal stakeholders, particularly in high-touch or sensitive situations. - Maintain a composed, professional demeanor when handling difficult or escalated interactions. - Act as a liaison across departments to facilitate timely and effective solutions. - Coordinate with internal teams to resolve issues related to benefits, claims, prior authorizations, and appeals. - Support frontline team members by taking on complex cases from inbound calls, task queues, and "Contact Us" requests. - Navigate multiple systems and workflows to research, document, and resolve issues efficiently. - Ensure all interactions and resolutions are documented accurately in the system. - Ensure escalations are resolved within established service level agreements. - Educate members and clients on plan benefits, coverage, and processes including prior authorization, formulary, and appeals. - Identify trends in escalations and provide feedback to improve workflows and member experience. - Participate in team huddles, training sessions, and performance reviews. - Maintain detailed and accurate records of all interactions. - Adhere to compliance standards, privacy regulations, and internal protocols. - Performs other related duties as assigned or requested. Any one position may not include all the duties listed. The job description identifies the responsibilities and tasks typically associated with the performance of the position. Required Experience - 2+ years in member services, healthcare operations, or pharmacy benefit management, preferably in a high-touch or escalation-focused role. - Demonstrated experience handling escalated member or client concerns with professionalism and accuracy. - Advanced written and verbal communication skills, particularly in high-pressure situations. - Strong ability to assess situations quickly and resolve issues independently. - Experience using CCaaS, Microsoft Office, and CRM platforms. - Experience managing task queues and complex workflows with attention to detail and follow-through. - Ability to collaborate cross-functionally and drive solutions across multiple teams. Preferred Experience - Experience in pharmacy benefits, managed care, or healthcare navigation. - Familiarity with prior authorization, formulary management, and appeals processes. - Experience with claims processing and rejection resolution, including pharmacy systems and tools (e.g., Tritium, Five9). - Exposure to compliance and quality assurance in member-facing roles. - Strong cross-functional collaboration skills, with demonstrated ability to work effectively with multiple teams and leadership.

You could be the one who changes everything for our 28 million members as a clinical professional on our Medical Management/Health Services team. Centene is a diversified, national organization offering competitive benefits including a fresh perspective on workplace flexibility. *Qualified candidates must be able to work 2:00PM-10:30PM EST.* Must be authorized to work in the U.S. without the need for employment-based visa sponsorship now or in the future. Sponsorship and future sponsorship are not available for this opportunity, including employment-based visa types H-1B, L-1, O-1, H-1B1, F-1, J-1, OPT, or CPT. Position Purpose: The Senior Pharmacy Resolution Specialist will act as a subject matter expert and handles more complex pharmacy issues and respond to escalated calls from members, provider/physician's offices and pharmacies. This role will make outbound calls and enters pharmacy overrides into systems based on approved guidelines and approvals provided from clinical pharmacists. - Takes member/prescriber/pharmacist inquiry calls for benefit questions including prior authorization requests - Offers options including submission of a prior authorization request - Thoroughly researches issues and takes appropriate action to resolve them using the appropriate reference material within turnaround time requirements and quality standards - Answers and conducts inbound and outbound calls with members and provider offices to provide resolution to claims (i.e.: additional information requests and medication determination updates) - Thoroughly researches issues and takes appropriate action to resolve them within turnaround time requirements and quality standards - Assists team members often guiding them to the appropriate resolution of more complex and difficult inquiries - Participates in the training of less experienced staff, including opportunity for job shadowing - Acts as a liaison between internal departments on data gathering and problem solving while investigating problems of an unusual nature in the area of responsibility - Presents proposed solutions in a clear and concise manner - Assists with audit preparation as needed - Assists with miscellaneous special project work as assigned - Performs other duties as assigned - Complies with all policies and standards Education/Experience: High School Diploma / GED. 2 years of experience. Call center / customer service experience. Experience in healthcare environment (pharmacy operations, managed care, pharmacy hospitals and or pharmacy retail settings). License/Certification: Pharmacy technician certification preferred. Pay Range: $19.43 - $32.98 per hour Centene offers a comprehensive benefits package including: competitive pay, health insurance, 401K and stock purchase plans, tuition reimbursement, paid time off plus holidays, and a flexible approach to work with remote, hybrid, field or office work schedules. Actual pay will be adjusted based on an individual's skills, experience, education, and other job-related factors permitted by law, including full-time or part-time status. Total compensation may also include additional forms of incentives. Benefits may be subject to program eligibility. Centene is an equal opportunity employer that is committed to diversity, and values the ways in which we are different. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, veteran status, or other characteristic protected by applicable law. Qualified applicants with arrest or conviction records will be considered in accordance with the LA County Ordinance and the California Fair Chance Act

The Revenue Cycle Supervisor at ruralMED, is responsible for the daily supervision and coordination of billing specialists who perform hands-on billing functions for assigned clients. This role ensures productivity, quality, and compliance standards are consistently achieved while supporting staff development, resolving escalated issues, and maintaining adherence to payer policies and CMS regulations. The Revenue Cycle Supervisor also serves as a key point of contact for clients, responsible for monitoring performance metrics, addressing operational issues, and maintaining strong client relationships through regular communication and collaboration. The Revenue Cycle Supervisor reflects the mission, vision, and values of ruralMED, adheres to the organization’s Code of Ethics and Corporate Compliance Program, and complies with all relevant policies, procedures, guidelines, and regulatory and accreditation standards.

Remote, Nationwide – Seeking Senior Coding Specialist Everybody Has A Role To Play In Transforming Healthcare As a Senior Coding Specialist, you play a vital role in our mission to improve lives. You are a vital member of the Coding team, reviewing physician documentation on medical charts and assigning correct CPT and ICD-10 codes in accordance with payer statues and regulations. At Vituity we know the impact you can have. Join the Vituity Team. At Vituity we’ve cultivated an environment where passion thrives, and success comes through shared purpose. We were founded in a culture that values team accomplishments more than individual achievements, an approach we call “culture of brilliance.” Together, we leverage our strengths and experiences to make a positive impact in our local communities. We foster this through shared goals and helping our colleagues succeed, and we also understand the importance of recognition, taking the time to show appreciation and gratitude for a job well done. Vituity Locations: Vituity has opportunities at 890 practices across the country, serving 14.5 million patients a year. With Vituity, if you ever need to move, you can take your job with you. The Opportunity - Review and comprehend Clinician documentation for various complex specialty practice lines on multiple coding platforms. - Apply Current Procedural Terminology (CPT) and International Classification of Diseases, Tenth Revision (ICD 10) codes in accordance with all Federal, State, and private payor statutes and regulations. - Notify Clinician of insufficient or ambiguous documentation and request clarification using the turnaround document (TAD) process. - Stay current with coding practices by attending scheduled educational sessions and seminars. - Monitor timekeeping for accuracy and notify Associate Manager, Coding of corrections. - Travel may be required up to 5%25 of the time. - Assist with special projects. Required Experience and Competencies - High school diploma or general education degree (GED) required. - Certificate of completion of a medical coding course that includes medical terminology required. - 1-2 years of coding experience required. - Some level of experience in “hands on” patient care; basic knowledge of pathology and etiology of disease, body areas and organ system desired. - Certified Professional Coder (CPC) is preferred. - Knowledge of pathology and etiology of disease, body areas and organ systems. - Strong understanding of medical terminology. - Thorough understanding of Current Procedural Terminology (CPT) and International Classification of Diseases, Tenth Revision (ICD 10). - Must have critical thinking and analytical skills. - Ability to work under pressure to meet production and quality standards. - Must have excellent judgement and reasoning abilities to make appropriate medical decisions. - Accurate data entry skills. - This dedicated and self-motivated person demonstrates attention to detail which promotes accuracy. - Ability to prioritize workflow and work autonomously. - Basic understanding of Microsoft Office applications (Word, Excel, and Outlook). The Community Even when you are working remotely, you are an important part of the Vituity Community. We offer plenty of opportunities to engage with other Vitans through a variety of virtual meet-and-greets, events and seminars. - Monthly wellness events and programs such as yoga, HIIT classes, and more. - Trainings to help support and advance your professional growth. - Team building activities such as virtual scavenger hunts and holiday celebrations. - Flexible work hours. - Opportunities to attend Vituity community events including LGBTQ+ History, Día de los Muertos Celebration, Money Management/Money Relationship, and more. Benefits & Beyond* Vituity cares about the whole you. With our comprehensive compensation and benefits package, we are mindful of what matters most, and support your needs of today and your plans for the future. - Superior health plan options - Dental, Vision, HSA/FSA, Life and AD&D coverage, and more - Top Tier 401(k) retirement savings plans that offers a $1.20 match for every dollar up to 6%25 plus discretionary profit-sharing contributions (eligible January following 18 months of service) - Generous paid time off starting 3-4 weeks’ annually - Student Loan Refinancing Discounts - Professional and Career Development Program - EAP and travel assistance included - Wellness program - Purpose-driven culture focused on improving the lives of our patients, communities, and employees We are excited to share the base salary range for this position is $20.80 - $25.48, exclusive of fringe benefits or potential bonuses. This position is also eligible to participate in our annual corporate Success Sharing bonus program, which is based on the company’s annual performance. If you are hired at Vituity, your final base salary compensation will be determined based on factors such as skills, education, and/or experience. We believe in the importance of pay equity and consider internal equity of our current team members as a part of any final offer. Please speak with a recruiter for more details. We are unified around the common purpose of transforming healthcare to improve lives and we believe everyone has a role to play in that. When we work together across sites and specialties as an integrated healthcare team, we exceed the expectations of our patients and the hospitals and clinics we work in. If you are looking to make a difference, from clinical to corporate, Vituity is the place to do it. Come grow with us. Vituity does not discriminate against any person on the basis of race, creed, color, religion, gender, sexual orientation, gender identity/expression, national origin, disability, age, genetic information (including family medical history), veteran status, marital status, pregnancy or related condition, or any other basis protected by law. Vituity is committed to complying with all applicable national, state and local laws pertaining to nondiscrimination and equal opportunity. *Benefits for part-time and per diem vary. Please speak to a recruiter for more information. Applicants only. No agencies please.