Member Service Guide, Complaint Resolution

Role overview Handle member complaints and grievances for a health plan, investigating concerns, finding fair resolutions, and helping members understand what happens next. The work combines careful case review, clear communication, accurate documentation, and adherence to regulatory deadlines, with coordination across internal teams when needed.

Responsibilities - Review case records, member information, and applicable policies to understand the cause of each grievance. - Resolve cases independently when possible, choosing practical solutions and connecting members with relevant programs or resources. - Escalate complex cases and coordinate with teammates or other internal partners to gather information and complete investigations. - Communicate by phone and in writing, tailoring explanations to members’ needs and confirming next steps. - Categorize and route cases, keep records accurate across multiple systems, and meet required resolution timelines. - Manage changing workloads, share case themes and process improvement ideas, and adapt to updated workflows or team priorities.

Requirements - Experience handling Medicare Advantage appeals and grievances. - Strong customer service and conflict resolution skills, including care when supporting frustrated or vulnerable members. - Clear written and verbal communication, with the ability to explain complex information simply. - Reliable organization, time management, attention to detail, and data accuracy. - Ability to work independently and collaboratively as regulations, priorities, or case volumes change. - Ability to obtain and maintain access to the federal health plan management system, including completing required security and training steps.

Nice to have - A degree or equivalent experience in healthcare, conflict resolution, or a related field. - Familiarity with insurance products, claims, policies, and procedures; strong investigative and analytical skills; and experience escalating cases. - Comfort documenting work across multiple computer systems.

Benefits and work setup The position is five days per week. The stated operating hours are 8 a.m. to 2 a.m. Eastern, Monday through Friday; the listing describes an 8.5-hour shift including a 30-minute meal break. Full-time benefits listed include health, dental, and vision coverage, paid time off, a monthly mobile or internet stipend, stock options, bonus eligibility, parental leave, and a retirement plan.