The Member Resolution Specialist role is primarily responsible for comprehensive follow-up and resolution of member billing inquiries and complex member issues. This position ensures validation of cases, maintains communication with providers, manages claim tracking, and confirms resolution with members. The role also supports Member Services Representatives during peak call volumes.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Professionally manages complex member billing issues after initial triage by Member Services Representatives.
• Handles cases originating from member centers via email or fax, managing initial outreach and subsequent follow-ups.
• Ensures thorough validation and comprehensive investigation of each case.
• Maintains ongoing communications with providers and tracks claims from submission through payment.
• Confirms resolution directly with members, ensuring satisfaction.
• Manages complex member issues requiring extensive investigation that do not qualify as grievances or appeals.
• Provides backup support to Member Services Representatives during periods of high call volume.
• Clearly documents case progress, communications, and resolutions in the call center system.
• Develops and maintains positive member relations, ensuring consistent and efficient resolution of issues.
• Actively participates in training and department meetings.
• Complies with organizational policies and procedures, maintaining confidentiality according to state and federal laws.

REQUIRED QUALIFICATIONS

• Bilingual in Spanish and English.
• Knowledge and experience working with Medicare and Medicare products, preferably through a Medicare Advantage Organization.
• Minimum one (1) year of experience in member services, billing, or claims resolution within insurance managed care, preferably a Medicare HMO.
• Basic understanding of Medicare regulatory requirements and standard operating procedures.
• Proficient in Microsoft Word, Microsoft Excel, and CRM software

CERTIFICATES, LICENSES, REGISTRATIONS

• Billing / Coding License Preferred.