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Escalations Specialist

3 months ago

Temple, United States Baylor Scott & White Health Full time

JOB SUMMARY

The Escalations Specialist investigates, evaluates and resolves member and provider issues or complaints for Commercial, Medicaid, Medicare and Marketplace products. Responsibilities include, but are not limited to: timely classification and resolution of cases, review, research and root cause research. Also includes coordination and interaction with other health plan departments for issue resolution. The Specialist is also accountable for member and provider manual updates, communication, education and training, and providing feedback for the internal knowledge-based tool.

ESSENTIAL FUNCTIONS OF THE ROLE

  • Examines and evaluates documentation to assess member/provider issues/complaints.
  • Conducts research and root cause research according to level of criticality and applies business acumen to resolve complaint/issue.
  • Identifies potential operations gaps and provides recommendations for process improvement implementation based on root cause research.
  • Examines benefits, eligibility, premiums and claims, and partners with various departments to correct processes, systems or policies, as needed.
  • Conducts regular follow-up with member/provider based on level of criticality until issue has been resolved and completed.
  • Communicates effectively with members/providers regarding policies, procedures and services to ensure knowledge of the benefits plan.
  • Documents all transactions and phone log records with the member/provider throughout the duration of the escalation and until full resolution is obtained.
  • Assesses the member/provider website and communication content, ensuring it is updated and accurate.
  • Accountable for member/provider manual updates, education and training.

KEY SUCCESS FACTORS

  • Excellent social skills are essential.
  • Advanced oral and written communication required.
  • Must be able to appropriately identify and prioritize urgent situations.
  • Requires the ability to plan and manage multiple priorities within a fast-paced office environment.
  • Must possess excellent organization and problem-solving skills, insightful reasoning and ability to examine information.
  • Attention to detail necessary to act within a complex environment.
  • Flexibility to respond to changing needs in the department.
  • Must be able to work well exclusively and as a team member.
  • Ability to recognize and know delicate customer-oriented issues.
  • Preferred experience in healthcare setting.
  • General knowledge of CPT coding, diagnosis coding, medical terminology and medical billing processes.

BENEFITS

Our competitive benefits package includes the following

  • Immediate eligibility for health and welfare benefits
  • 401(k) savings plan with dollar-for-dollar match up to 5%
  • Tuition Reimbursement
  • PTO accrual beginning Day 1

Note: Benefits may vary based upon position type and/or level

QUALIFICATIONS

- EDUCATION - Bachelor's or 4 years of work experience above the minimum qualification

- EXPERIENCE - 2 Years of Experience