Service Resolution Specialist

This is a fully remote position, open to applicants in United States.

📋 Description

• Address second-level escalations that exceed the capabilities of first-line customer service representatives concerning claims, eligibility, benefits, and billing inquiries.

• Conduct thorough investigations into issues, document the findings, and log all activities in the centralized escalation tracker.

• Identify the root cause when feasible; if the issue pertains to education, engage directly with the member to provide necessary information.

• Support escalated call audits and tracking efforts currently managed by the Customer Service Director.

• Refer to an ESR when faced with technically complex issues or those requiring specialized knowledge, ensuring a clear and documented transition.

• Implement authorized immediate actions within your scope and direct “send-on” items to the appropriate team.

• Adhere to acknowledgment, response, and resolution service level agreements (SLAs) based on the severity of issues.

• Manage all client-facing communications through Account Management and the RRT to prevent conflicting or untracked messages.

• Highlight recurring issues and emerging trends to the RRT to aid in trend analysis and root cause identification.

⛳️ Requirements

• A high school diploma or GED is required; an associate or bachelor's degree is preferred.

• A minimum of 2 years of experience in health benefits customer service, claims, or member services is necessary.

• Familiarity with claims processing, eligibility, and benefit structures is essential.

• Proficient in CRM/ticketing systems (e.g., Zendesk) and standard office software.

• Excellent written and verbal communication skills with a focus on customer service.

• Experience in a third-party administrator (TPA), health plan, or pharmacy benefit manager (PBM) setting is advantageous.

• Knowledge of medical coding and billing principles is a plus.

• Previous experience in escalation, second-level, or issue-resolution support is beneficial.

🏝️ Benefits

• Comprehensive medical, dental, vision, and life insurance coverage.

• 401(k) retirement plan with employer match.

• Health Savings Account (HSA) & Flexible Spending Accounts (FSAs).

• Paid time off (PTO) and disability leave.

• Employee Assistance Program (EAP).