Case Resolution Specialist I

1. Conducts critical analysis of highly complex and sensitive member and provider appeals, inquiries and grievances and applies internal policies and procedures, contractual provisions, and regulatory requirements.
   
   • Secures information from internal and external resources to resolve issues.
   • Assists Supervisor and Coordinator in working as a liaison with providers, members and internal decision makers in representing HMSA objectives, goals, and expectations for meeting contractual, regulatory, and accreditation requirements.
   • Negotiates/resolves sensitive issues with internal and external parties.
   • Takes all facts and research from internal and external resources and presents a full explanation of the member's or provider's position and concerns to management and decision makers.
   • Triages cases to resolve them upon initial inquiry to best service the member as well as minimize the number of cases escalated to senior management and e...

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