By leveraging our world-class technology platform, innovative care delivery models, deep physician partnerships and our serving heart culture, Alignment Health is championing a new path in senior care! From member experience professionals and clinicians to data scientists and operations leaders, we have built a talented and passionate team that is committed to our mission of transforming health care for the seniors we serve. Ready to join us?

At Alignment, delivering exceptional care to seniors starts with ensuring an exceptional experience for our employees. At the center of our employee experience is a culture where employees at all levels and across all teams are encouraged to share their unique ideas and perspectives. Whether you're in a clinical setting, corporate office, or home office, we believe in supporting continuous learning and growth for your career.

The Resolutions Specialist provides member issue resolution managing and resolving healthcare insurance claims in a timely and accurate manner. This role requires solid analytical skills, knowledge of healthcare insurance policies, and a commitment to providing exceptional service to policyholders, healthcare providers, and internal stakeholders.

RESPONSIBILITIES:
1. Serves as a "subject matter expert" in escalated member calls (authorizations, claims, provider network issues) and be able to resolve these escalations based on level of understanding / experience of healthcare processes and protocols.
2. Identifies process improvement opportunities within the member engagement department given the collaboration with different departments.
3. Knowledgeable in procedures, protocols, benefits, services, and any other necessary information to resolve member issues and inquiries.
4. Conducts outbound phone calls and / or receive 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. Collaborates with our partners, including other departments, supplemental benefit vendors, and provider network, to facilitate the member experience.
6. Identifies 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. Documents real-time and conduct timely wrap-up to support outcomes reporting in all systems / applications by entering member demographics and information with accuracy and pay attention to detail, focusing on data integrity in support of quality organizational data.
8. Provides excellent customer service and contribute to a culture of going "above and beyond" to ensure the highest level of member satisfaction.
9. Participates in all required team meetings and trainings and demonstrate satisfactory understanding of new information and process.
10. Assist with development and training of new hires including shadowing and nesting.
11. Other duties as assigned

Job Requirements:

Experience:
• Required: Minimum one (1) year healthcare experience. Minimum one (1) year 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. 1+ years of experience helping members navigate access to care through Medicare Advantage or HMO, including referrals and authorizations. Minimum 1 year experience helping members navigate their Medicare Advantage benefits including medical, prescription drug, and supplemental benefits.
• Preferred: 3-4 years of healthcare experience

Education:
• Required: High School Diploma or GED.
• Preferred: College courses

Specialized Skills:
• Required:

• Able to describe, explain, and educate our members about health plan coverage and services.
• Ability to communicate positively, professionally and effectively with others; provide leadership, teach and collaborate with others.
• Effective written and oral communication skills; ability to establish and maintain a constructive relationship with diverse members, management, employees and vendors;
• Intermediate proficiency in Microsoft Office Suite (Outlook, Word, Excel) required
• Able to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Able to write routine reports and correspondence. Able to speak effectively before groups of customers or employees of the organization.
• Able to add and subtract two-digit numbers and to multiply and divide with 10's and 100's. Able to perform these operations using units of American money and weight measurement, volume, and distance.
• Able to apply common sense understanding to carry out detailed, but un-involved written or oral instructions. Able to deal with problems involving a few concrete variables in standardized situations.
• Reasoning Skills: Ability to prioritize multiple tasks; advanced problem-solving; ability to use advanced reasoning to define problems, collect data, establish facts, draw valid conclusions, and design, implement and manage appropriate resolution.
• Problem-Solving Skills: Effective problem solving, organizational and time management skills

• Preferred: Bilingual English andSpanish, Chinese (Mandarin or Cantonese), or Vietnamese.

Licensure:
• Required: None

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.

1. 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.

2. 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.
Pay Range: $41,600.00 - $57,600.00

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health's talent acquisition team, please email careers@ahcusa.com.