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Alignment HealthCore Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in healthcare insurance claims resolution, member communication, and process improvement. Proficient in managing member inquiries and navigating Medicare Advantage benefits while providing exceptional customer service.
Highest-signal resume keywords
Healthcare ExperienceOutbound Call Center ExperienceMedicare Advantage NavigationBilingual CommunicationMicrosoft Office Suite Proficiency
About the role
Key responsibilities & impact- Provide member issue resolution for healthcare insurance claims
- Intake complex member cases and provide prompt, satisfactory resolution
- Serve as a subject matter expert for escalated member calls involving authorizations, claims, and provider network issues
- Identify process improvement opportunities within the member engagement department
- Explain procedures, protocols, benefits, and services to resolve member issues and inquiries
- Conduct outbound and receive inbound calls within department timeframes
- Manage member communication preferences, including time of day, channel, and language
- Collaborate with departments, supplemental benefit vendors, and provider network partners
- Identify members for care gaps and campaigns, analyze program eligibility, and connect members with appropriate programs, providers, or vendors
- Document member information accurately in systems and applications and complete timely wrap-up activities
- Submit activity reports and meet individual and team goals
- Participate in required team meetings and trainings
- Adhere to attendance and productivity policies
- Assist with development and training of new hires through shadowing and nesting
Requirements
What you’ll need- Minimum (1) year healthcare experience and/or training required; 3-4 years of healthcare experience/training required
- Minimum (1) year outbound call center experience and/or inbound call center experience involving escalation or resolution
- Experience helping members navigate access to care through Medicare Advantage or HMO, including referrals and authorizations
- Experience helping members navigate Medicare Advantage benefits, including medical, prescription drug, and supplemental benefits
- High school diploma or GED; or equivalent combination of education and experience
- Intermediate proficiency in Microsoft Office Suite (Outlook, Word, Excel)
- Bilingual English and Spanish, Chinese (Mandarin or Cantonese), or Vietnamese
- Ability to work full-time and overtime during Annual Enrollment Period and Open Enrollment Period
- Ability to troubleshoot, problem solve, interpret documents, write routine reports and correspondence, and speak effectively before groups
- Ability to perform basic arithmetic using American money and measurement units
- Ability to follow detailed written or oral instructions and solve problems involving standardized situations
- Independent, motivated self-starter able to prioritize work assignments
- Team-oriented and willing to support colleagues
- Passion for customer service and member retention
- Comfortable being on the phone
Benefits
Comp & perks- Full-time employment
- Overtime availability during the Annual Enrollment Period and Open Enrollment Period
- Opportunities for growth and innovation
- Equal Opportunity/Affirmative Action employment
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Claims ResolutionMember Issue ResolutionProcess ImprovementDocumentation AccuracyBasic ArithmeticTroubleshootingProblem SolvingReport WritingMember Eligibility AnalysisCare Gap Identification
Soft Skills
Customer ServiceTeam CollaborationIndependent Self-StarterEffective CommunicationMotivation
Certifications & Qualifications
High School DiplomaGED
Industry Keywords
Healthcare InsuranceMedicare AdvantageHMOMember EngagementProvider NetworkSupplemental BenefitsCall Center OperationsMember RetentionEnrollment PeriodsCommunication Preferences