Duties and Responsibilities + Responsible for case development and resolution of non-clinical cases, such as: certain types of claim denials, member complaints, and member and provider appeals. The end-to-end process requires the Specialist to independently: + Research issues + Reference and understand HFs internal health plans policies and procedures to frame decisions + Interpret regulations + Resolve cases and make critical decisions + Edit and finalize resolution letters + Manage all duties within regulatory timeframes + Communicate effectively to hand-off or pick-up work from colleagues + Work within a framework that measures productivity and quality for each Specialist against expectations + Additional duties as assigned **Minimum Qualifications** + High School Diploma or GED + Bachelors degree from an accredited institution or relevant work experience **Preferred Qualifications** + Minimum of two (2) years of work experience in Managed Care or Health Insurance + Work experience in claims, customer service, home health, hospital or doctors office preferred + Experience working in care management systems, such as CCMS, TruCare or Hyland + Demonstrated critical thinking and decision-making competencies + Highly effective communication, organizational, and customer service skills + Demonstrated ability to be detail oriented, work under pressure, manage tight timeframes WE ARE AN EQUAL OPPORTUNITY EMPLOYER. Applicants and employees are considered for positions and are evaluated without regard to mental or physical disability, race, color, religion, gender, gender identity, sexual orientation, national origin, age, genetic information, military or veteran status, marital status, mental or physical disability or any other protected Federal, State/Province or Local status unrelated to the performance of the work involved.