Own and resolve high-priority, complex, or sensitive member escalations end-to-end.
Serve as the “last line” point of contact for unresolved member concerns.
Investigate grievances thoroughly, synthesizing information from multiple systems and stakeholders.
Ensure timely, compliant, and well-documented resolution of all escalations.
Review and assess accommodation and accessibility requests with sound judgment and consistency.
Evaluate supporting documentation, including authorized representative forms and related records.
Determine appropriate next steps, including approvals, denials, or escalations.
Partner with internal teams to ensure accommodations are implemented and documented effectively.
Communicate professionally and clearly with health plans, providers, and external partners.
Adapt communication style based on audience (members, executives, clinical and member support teams, partners).
Translate complex issues into actionable insights for internal stakeholders.
Lead de-escalation efforts with empathy, professionalism, and control.
Make independent, high-stakes decisions within established guidelines.
Identify when to escalate issues further vs. resolve directly.
Recognize patterns and recommend improvements to reduce future escalations.

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