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Case Resolution Specialist I

Company: HMSA
Location: Honolulu
Posted on: January 25, 2023

Job Description:



  • 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 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 accreditation requirements.

    • Proposes changes to management based on identification and analysis.

    • 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 Coordinator.

    • Assists with the implementation of resulting decisions for change/resolution.

    • 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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