Role Description
The Resolution Specialist is responsible for managing and resolving complex member issues through proactive outreach, case ownership, and cross-functional coordination. This role serves as a frontline problem solver ensuring member concerns related to items such as authorizations, claims, benefits, provider access, and service experience are resolved accurately, compassionately, and within defined turnaround times.
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Fully own assigned cases from intake through closure, ensuring members feel heard, supported, and confidently resolved.
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Contribute to improving turnaround times, reducing aging inventory, and delivering a high-quality member experience aligned with regulatory and organizational standards.
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Support the Customer Resolution team’s mission of delivering caring connections while identifying trends and improvement opportunities that strengthen operational performance and prevent repeat issues.
Qualifications
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Minimum 1 year of healthcare experience.
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Minimum 1 year of contact center experience involving complex problem solving, escalation handling, or issue resolution.
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Experience assisting members with navigating healthcare services including referrals, authorizations, claims, or benefits.
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Experience supporting Medicare Advantage or managed care members with benefits navigation including medical, prescription drug, or supplemental benefits.
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Preferred: 3+ years healthcare experience.
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Preferred: Experience in grievance, escalation, or resolution-focused contact center environments.
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Preferred: Medicare Advantage or managed care experience.
Requirements
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Required: High School Diploma or GED.
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Preferred: College coursework in healthcare administration, business, or related field.
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Required: None for training.
Benefits
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Pay Range: $41,600.00 - $57,600.00 based on factors including market location, education, responsibilities, experience, etc.
Job Duties/Responsibilities
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Case Resolution & Member Experience:
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Manage assigned member resolution cases from intake through final closure, ensuring complete and timely resolution of member concerns.
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Serve as a subject matter resource for escalated member issues including claims, authorizations, referrals, benefits clarification, provider network concerns, and access to care.
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Conduct outbound outreach and handle inbound contacts to investigate, resolve, and communicate case outcomes within established turnaround time expectations.
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Provide clear explanations of health plan benefits, coverage policies, services, and available resources to ensure members understand their options and next steps.
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Demonstrate empathy, professionalism, and accountability while maintaining a “caring connection” mindset to fully resolve member issues whenever possible.
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Support other customer experience teams including inbound as needed.
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Case Management & Documentation:
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Maintain accurate and detailed case documentation in all required systems to support resolution tracking, regulatory compliance, and reporting.
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Ensure timely case updates, proper categorization, and completion of required wrap-up activities to maintain data integrity.
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Manage assigned caseload to support departmental goals for case closure rates, productivity, and aging inventory reduction.
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Monitor case progress and proactively escalate barriers that may delay resolution.
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Cross-Functional Coordination:
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Collaborate with internal departments including Operations, Clinical, Claims, Enrollment, Provider Relations, and Compliance to resolve complex member concerns.
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Coordinate with external partners such as provider offices, supplemental benefit vendors, and interpreter services when required to facilitate member resolution.
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Ensure member cases requiring multi-department engagement are tracked through completion and properly communicated to the member.
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Quality, Compliance & Service Excellence:
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Ensure all resolution activities adhere to CMS, regulatory, and organizational compliance standards.
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Deliver high-quality service that supports member satisfaction, retention, and service recovery.
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Apply critical thinking and problem-solving skills to identify the root cause of member concerns and prevent repeat contacts when possible.
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Continuous Improvement & Team Support:
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Identify recurring issues, barriers, or trends impacting member experience and share insights with leadership for process improvement.
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Participate in quality reviews, coaching sessions, and performance discussions to strengthen resolution skills and service delivery.
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Support team learning and development through knowledge sharing, peer support, and participation in training initiatives.
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Assist with onboarding and mentoring of new hires through shadowing or knowledge transfer when requested.
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Additional Responsibilities:
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Participate in team meetings, training sessions, and departmental initiatives.
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Support organizational campaigns such as care gap outreach or benefit education when applicable.
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Perform other duties as assigned to support team objectives and member service goals.
