Resolution Specialist (MUST HAVE 2+ YEARS OF PBM/ADJACENT EXPERIENCE)

Position Summary

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.

Responsibilities

• 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.


• Performs other related duties as assigned or requested. Any one position may not include all the duties listed. The job description identifies the responsibilities and tasks typically associated with the performance of the position.

Required Experience

• 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.