Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.

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.

Overview of the Role:

Alignment Health is seeking a bilingual Spanish resolution specialist to join the member engagement team to provide member issue resolution. As a resolution specialist, you will intake complex member cases and provide prompt and satisfactory resolution. You will be dedicated to decreasing turnaround time, improving the quality of resolution, and managing barriers to resolution as part of process improvement and Voice of the Customer (VoC).

Schedule: Monday through Friday

Between 8:00am - 5:00pm Pacific Time
Between 9:00am - 6:00pm Mountain Time
Between 10:00am - 7:00pm Central Time
Between 11:00am - 8:00pm Eastern Time

No Time Off Approved During:

No time off is permitted during the first (5) week training period.
Annually during entire month of January due to it being the busiest time of the year (no exceptions)

Responsibilities:

Serve 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.
Identify process improvement opportunities within the member engagement department given the collaboration with different departments.
Knowledgeable in procedures, protocols, benefits, services, and any other necessary information to resolve member issues and inquiries.
Conduct 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.
Collaborate with our partners, including other departments, supplemental benefit vendors, and provider network, to facilitate the member experience. Identify 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.
Document 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.
Meet and exceed individual and team goals by submitting activity reports in the format and frequency required. Provide excellent customer service and contribute to a culture of going “above and beyond” to ensure the highest level of member satisfaction.
Participate in all required team meetings and trainings and demonstrate satisfactory understanding of new information and process.
Adhere to all applicable attendance and productivity policies.
Assist with development and training of new hires including shadowing and nesting.

Required Skills and Experience:
Minimum (1) year healthcare experience and / or training required; 3-4 years of healthcare experience / training required.
Minimum (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.
Experience helping members navigate access to care through Medicare Advantage or HMO, including referrals and authorizations.
Experience helping members navigate their Medicare Advantage benefits including medical, prescription drug, and supplemental benefits.
High school diploma or general education degree (GED); or equivalent combination of education and experience.
Intermediate proficiency in Microsoft Office Suite (Outlook, Word, Excel) required Bilingual English and Spanish, Chinese (Mandarin or Cantonese), or Vietnamese.
Independent, motivated, self-starter who can prioritize work assignments and make every day a productive day.
Team player willing to help and support colleagues and do their part to support us all reaching our organizational goals.
Learn, describe, explain, and educate our members about health plan coverage and services.
Passionate about customer service and member retention
Excellent customer service and comfortable being on the phone.
Able to troubleshoot and problem solve.
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.

Work Environment

Must be available annually to work full-time and over-time through the Annual Enrollment Period (October through December) and Open Enrollment Period (January through March)

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.