Remote-Resolution Specialist Full Time NEW

Alignment Health is breaking the mold in conventional health care, committed to serving seniors and those who need it most: the chronically ill and frail. It takes an entire team of passionate and caring people, united in our mission to put the senior first. We have built a team of talented and experienced people who are passionate about transforming the lives of the seniors we serve. In this fast-growing company, you will find ample room for growth and innovation alongside the Alignment Health community. Working at Alignment Health provides an opportunity to do work that really matters, not only changing lives but saving them. Together.

The Resolution Specialist is responsible for managing and resolving complex member issues through proactive outreach, case ownership, and cross-functional coordination. This role serves as a frontline problem solver ensuring member concerns related to items such as authorizations, claims, benefits, provider access, and service experience are resolved accurately, compassionately, and within defined turnaround times.

Resolution Specialists fully own assigned cases from intake through closure, ensuring members feel heard, supported, and confidently resolved. Working within a structured case management environment, this role contributes to improving turnaround times, reducing aging inventory, and delivering a high-quality member experience aligned with regulatory and organizational standards.

This position plays a critical role in supporting the Customer Resolution team’s mission of delivering caring connections while identifying trends and improvement opportunities that strengthen operational performance and prevent repeat issues.

Job Duties/Responsibilities

Case Resolution & Member Experience

• Manage assigned member resolution cases from intake through final closure, ensuring complete and timely resolution of member concerns.
• Serve as a subject matter resource for escalated member issues including claims, authorizations, referrals, benefits clarification, provider network concerns, and access to care.
• Conduct outbound outreach and handle inbound contacts to investigate, resolve, and communicate case outcomes within established turnaround time expectations.
• Provide clear explanations of health plan benefits, coverage policies, services, and available resources to ensure members understand their options and next steps.
• Demonstrate empathy, professionalism, and accountability while maintaining a “caring connection” mindset to fully resolve member issues whenever possible.
• Support other customer experience teams including inbound as needed.

Case Management & Documentation

• Maintain accurate and detailed case documentation in all required systems to support resolution tracking, regulatory compliance, and reporting.
• Ensure timely case updates, proper categorization, and completion of required wrap-up activities to maintain data integrity.
• Manage assigned caseload to support departmental goals for case closure rates, productivity, and aging inventory reduction.
• Monitor case progress and proactively escalate barriers that may delay resolution.

Cross-Functional Coordination

• Collaborate with internal departments including Operations, Clinical, Claims, Enrollment, Provider Relations, and Compliance to resolve complex member concerns.
• Coordinate with external partners such as provider offices, supplemental benefit vendors, and interpreter services when required to facilitate member resolution.
• Ensure member cases requiring multi-department engagement are tracked through completion and properly communicated to the member.

Quality, Compliance & Service Excellence

• Ensure all resolution activities adhere to CMS, regulatory, and organizational compliance standards.
• Deliver high-quality service that supports member satisfaction, retention, and service recovery.
• Apply critical thinking and problem-solving skills to identify the root cause of member concerns and prevent repeat contacts when possible.

Continuous Improvement & Team Support

• Identify recurring issues, barriers, or trends impacting member experience and share insights with leadership for process improvement.
• Participate in quality reviews, coaching sessions, and performance discussions to strengthen resolution skills and service delivery.
• Support team learning and development through knowledge sharing, peer support, and participation in training initiatives.
• Assist with onboarding and mentoring of new hires through shadowing or knowledge transfer when requested.

Additional Responsibilities

• Participate in team meetings, training sessions, and departmental initiatives.
• Support organizational campaigns such as care gap outreach or benefit education when applicable.
• Perform other duties as assigned to support team objectives and member service goals.

Experience

Job Requirements

Required

• Minimum 1 year of healthcare experience.
• Minimum 1 year of contact center experience involving complex problem solving, escalation handling, or issue resolution.
• Experience assisting members with navigating healthcare services including referrals, authorizations, claims, or benefits.
• Experience supporting Medicare Advantage or managed care members with benefits navigation including medical, prescription drug, or supplemental benefits.

Preferred

• 3+ years healthcare experience.
• Experience in grievance, escalation, or resolution-focused contact center environments.
• Medicare Advantage or managed care experience.

Education

• Required: High School Diploma or GED
• Preferred: College coursework in healthcare administration, business, or related field

Training

• Required: None

Specialized Skills

• Required:
• Ability to clearly explain health plan coverage, benefits, and services to members.
• Strong verbal and written communication skills with the ability to build trust and rapport with members and partners.
• Effective problem-solving and analytical skills with the ability to investigate and resolve complex issues.
• Strong organizational and time management skills to manage multiple active cases.
• Ability to collaborate effectively with cross-functional teams and external partners.
• Intermediate proficiency in Microsoft Office Suite (Outlook, Word, Excel).
• Ability to read and interpret procedure manuals, policy documents, and operational guidelines.
• Ability to apply sound judgment and reasoning when evaluating member issues and determining appropriate resolution.
• Preferred:
• Bilingual English and Spanish, Chinese (Mandarin or Cantonese), or Vietnamese.

Licensure

• Required: None

Essential Physical Functions

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel and talk or hear. The employee is frequently required to walk; stand; reach with hands and arms. The employee is occasionally required to climb or balance and stoop, kneel, crouch, or crawl. The employee must occasionally lift and/or move up to 20 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Alignment Healthcare, LLC is proud to practice Equal Employment Opportunity and Affirmative Action. We are looking for diversity in qualified candidates for employment: Minority/Female/Disable/Protected Veteran.

If you require any reasonable accommodation under the Americans with Disabilities Act (ADA) in completing the online application, interviewing, completing any pre-employment testing or otherwise participating in the employee selection process, please contact careers@ahcusa.com.

Pay Range: $41,600.00 – $57,600.00

Pay range may be based on a number of factors including market location, education, responsibilities, experience, etc.

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

• DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email careers@ahcusa.com.