Resolution Response Specialist

Key Responsibilities

• Own escalated member cases end-to-end, serving as the single accountable owner for moderate-to-high complexity issues across billing, reimbursement, benefits, coordination of benefits, network exceptions, and service breakdowns.
• Conduct structured investigations using the established triage framework (Category → Owner → Macro → Checklist → SLA → Escalation Path), reviewing ticket history, call recordings, prior guidance, client documentation, spend, and reimbursement records before resolution.
• Lead service recovery by reviewing low-rated interactions, conducting proactive outreach (call-first where possible), applying de-escalation protocols, and confirming closed-loop resolution with a written member recap.
• Serve as the primary cross-functional bridge across MBS, Support, Care Delivery, Client Success, Payment Operations, Network Operations, Product, Engineering, and Legal/Compliance to coordinate corrective action and accelerate resolution.
• Communicate with members using approved macros and empathy-led, legally protective language; provide CSMs with concise case summaries and polished client-facing messaging when needed.

Key Requirements

• Bachelor’s degree in Healthcare Administration, Business, Communications, or related field preferred, or equivalent experience; 3+ years in escalation management, member/customer advocacy, health benefits, or healthcare operations.
• Experience resolving complex, multi-stakeholder escalations; strong knowledge of employer-sponsored benefits, reimbursement and claims workflows, and the fertility/family-building member journey.
• Familiarity with Zendesk, Jira, Guru, Google Sheets, and Looker.
• Highly organized and detail-oriented, with strong critical thinking, root-cause analysis, and structured case management skills.
• Excellent verbal and written communication, with strong de-escalation skills and the ability to translate complex benefits and billing issues into clear resolution plans.