[Hiring] Resolution Specialist @DisclosedRx

Role Description

The Resolution Specialist is responsible for managing escalated member and client concerns, ensuring timely and effective resolution of complex issues. This role operates within a fast-paced remote environment and serves as a key escalation point for high-touch situations requiring advanced communication, critical thinking, and cross-functional coordination.

The Resolution Specialist ensures a positive member and client experience by maintaining professionalism under pressure, demonstrating strong ownership of issues, and facilitating solutions across internal teams.

• Manage and resolve escalated member and client issues with urgency and professionalism.
• Assess complex situations quickly and take prompt, independent action to drive resolution.
• Maintain ownership of escalated cases from intake through resolution, ensuring follow-through and closure.
• Communicate clearly and effectively with members, clients, and internal stakeholders, particularly in high-touch or sensitive situations.
• Maintain a composed, professional demeanor when handling difficult or escalated interactions.
• Act as a liaison across departments to facilitate timely and effective solutions.
• Coordinate with internal teams to resolve issues related to benefits, claims, prior authorizations, and appeals.
• Support frontline team members by taking on complex cases from inbound calls, task queues, and "Contact Us" requests.
• Navigate multiple systems and workflows to research, document, and resolve issues efficiently.
• Ensure all interactions and resolutions are documented accurately in the system.
• Ensure escalations are resolved within established service level agreements.
• Educate members and clients on plan benefits, coverage, and processes including prior authorization, formulary, and appeals.
• Identify trends in escalations and provide feedback to improve workflows and member experience.
• Participate in team huddles, training sessions, and performance reviews.
• Maintain detailed and accurate records of all interactions.
• Adhere to compliance standards, privacy regulations, and internal protocols.
• Perform other related duties as assigned or requested.

Qualifications

• 2+ years in member services, healthcare operations, or pharmacy benefit management, preferably in a high-touch or escalation-focused role.
• Demonstrated experience handling escalated member or client concerns with professionalism and accuracy.
• Advanced written and verbal communication skills, particularly in high-pressure situations.
• Strong ability to assess situations quickly and resolve issues independently.
• Experience using CCaaS, Microsoft Office, and CRM platforms.
• Experience managing task queues and complex workflows with attention to detail and follow-through.
• Ability to collaborate cross-functionally and drive solutions across multiple teams.

Preferred Experience

• Experience in pharmacy benefits, managed care, or healthcare navigation.
• Familiarity with prior authorization, formulary management, and appeals processes.
• Experience with claims processing and rejection resolution, including pharmacy systems and tools (e.g., Tritium, Five9).
• Exposure to compliance and quality assurance in member-facing roles.
• Strong cross-functional collaboration skills, with demonstrated ability to work effectively with multiple teams and leadership.