Case Resolution Specialist I
Posted on: January 25, 2023
- Conducts critical analysis of highly complex and sensitive
member and provider appeals, inquiries and grievances and applies
internal policies and procedures, contractual provisions, and
- Secures information from internal and external resources to
- 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
- 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
- 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 executives.
- At the direction and supervision of management, participates on
cross departmental committees and other internal meetings to
identify, clarify, research, and resolve inquiries and issues.
- Identifies when changes to policies and procedures are needed
based on case resolutions, statutory or regulatory changes, or
- Proposes changes to management based on identification and
- Analyzes and identifies issues that may require multiple
department efforts to resolve.
- Presents recommendations to internal committees, subgroups and
executive management for decision making purposes as it relates to
cases after discussion and approval from Supervisor and
- Assists with the implementation of resulting decisions for
- Assists supervisor/manager in responding to internal
investigations, reviews, and audits; regulatory inquiries; and
accreditation related audits.
- Assist internal customers with complex member/physician
inquiries with guidance and direction from management.
- Identifies member problems, member education needs, or trends
and report these to manager, as well as recommend resolution. Takes
a proactive role in reviewing, digesting and communicating any new
regulation, standard, business change, etc. affecting the member
advocacy and/or appeals process. At direction of management,
assists in the coordination of changes among departments.
- Performs quality assurance of case documents and assists
Supervisor and Manager with various corporate activities.
- Performs all other miscellaneous responsibilities and duties as
assigned or directed.
Keywords: HMSA, Honolulu , Case Resolution Specialist I, Other , Honolulu, Hawaii
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