As a Claims Advocacy Specialist, you will play a pivotal role in managing complex member claims escalations, ensuring that issues are resolved efficiently and accurately for our members. You will collaborate cross-functionally with internal teams, such as Member Care Advocacy, Service Quality, and Training, as well as external partners, such as customers and/or insurance companies, to navigate intricate claims escalations and achieve appropriate outcomes. Working closely with Claims Advocacy leadership, you will research operational challenges, identify opportunities for improvement, and contribute to the enhancement of the overall claims experience. The ideal candidate will be curious, quick to learn, and able to work both independently and collaboratively within a team setting. You will be passionate about solving problems, delivering world-class customer service, and driving improvements in healthcare and health outcomes for our members.
This role is an individual contributor and will report into the Manager of Claims Advocacy.Job Summary:Research escalations originating from members, clients and/or client successCollaborate with internal (e.g. Quality) and external partners (e.g. carriers) to ensure claims escalations are resolved and responded-to within defined turn-around-timesCreate action plans to address widespread issues raised by member feedbackDrive improvements through developing strategic contacts and internal collaborationAssist with process-development and problem-solving with external vendors and carriersDraft Job Aids to support new initiativesManage SOPs to reflect most current directivesMentor team members for performance improvementsTrain new hires and assist in onboarding processProvide team support for complex scenarios and finding resolutionsCollate member impact stories for newsletter, marketing and team impact as neededSupport team morale through difficult cases and adversityRequired Qualifications:2+ years experience in claims processing or revenue cycle managementMastery of de-escalation techniques and customer serviceShow initiative to identify and solve issues at scaleManage multiple priorities with strong decision-making abilityHighly organized and able to work with minimal supervisionDemonstrates high levels of emotional intelligence and empathyCurious nature- wanting to dig in and understand root causes of problemExperience working cross-functionallyStrong written and verbal communication skillsAbility to adapt to a changing environmentPhysical/Cognitive Requirements:Prompt and regular attendance at assigned work location.Ability to remain seated in a stationary position for prolonged periods.Requires eye-hand coordination and manual dexterity sufficient to operate keyboard, computer and other office-related equipment.No heavy lifting is expected, though occasional exertion of about 20 lbs. of force (e.g., lifting a computer / laptop) may be required.Ability to interact with leadership, employees, and members in an appropriate manner.About Included Health
Included Health is a new kind of healthcare company, delivering integrated virtual care and navigation. We’re on a mission to raise the standard of healthcare for everyone. We break down barriers to provide high-quality care for every person in every community — no matter where they are in their health journey or what type of care they need, from acute to chronic, behavioral to physical. We offer our members care guidance, advocacy, and access to personalized virtual and in-person care for everyday and urgent care, primary care, behavioral health, and specialty care. It’s all included. Learn more at .
-----Included Health is an Equal Opportunity Employer and considers applicants for employment without regard to race, color, religion, sex, orientation, national origin, age, disability, genetics or any other basis forbidden under federal, state, or local law. Included Health considers all qualified applicants in accordance with the San Francisco Fair Chance Ordinance.