Member Resolution Expert in Kalamazoo, Michigan at Optimed Pharmacy Inc

POSITION: Member Resolution Expert

Who We Are

OptiMed Health Partners optimizes health outcomes and quality of life through personalized and coordinated care. We have been serving patients for over 30 years with a focus on high-quality care in retail pharmacy, specialty pharmacy, and infusion services. The OptiMed Vision reimagines healthcare solutions to achieve unsurpassed value. Our results-oriented culture fosters learning, providing growth opportunities for our employees and exceptional care for our patients in all 50 states.

The Impact of This Role

The Member Resolution Expert serves as the operational owner of complex member issues requiring investigation, coordination, and resolution. This position is responsible for researching concerns across multiple pharmacy and healthcare systems, identifying root causes, coordinating cross-functional corrective actions, and clearly communicating findings, expectations, and next steps to members and stakeholders.

Acting as a liaison between members and internal departments, the Member Resolution Expert ensures issues are resolved efficiently while minimizing member effort, improving satisfaction, and identifying opportunities for operational improvement. The role requires strong knowledge of pharmacy operations, reimbursement processes, healthcare workflows, and the ability to navigate multiple systems and departments to drive successful outcomes.

To serve as the organizational owner of complex member issues by researching, coordinating, communicating, and driving resolution while improving the overall member experience and identifying opportunities for operational improvement. This role ensures members receive clear answers, coordinated support, and timely resolution through collaboration across all areas involved in the member journey.

What You'll Be Doing

Member Issue Resolution

• Serve as the primary owner for complex member issues, escalations, complaints, and service recovery opportunities.
• Conduct comprehensive investigations utilizing multiple pharmacy, reimbursement, billing, CRM, and operational systems.
• Analyze member records, workflows, communications, and transaction histories to determine root cause.
• Develop and execute resolution plans to address member concerns efficiently and effectively.
• Track and manage issues through resolution while ensuring all commitments and follow-up activities are completed.
• Escalate high-risk or sensitive issues to leadership when appropriate.
• Maintain accountability for issue resolution from initial identification through final closure.

Research & Analysis

• Gather and synthesize information from multiple departments, systems, and stakeholders.
• Investigate operational, clinical, reimbursement, dispensing, billing, shipping, and service-related issues.
• Utilize multiple pharmacy and business systems to identify gaps, breakdowns, and opportunities for intervention.
• Identify trends, recurring issues, and process failures contributing to member dissatisfaction.
• Prepare detailed case summaries outlining findings, root causes, recommendations, and resolution activities.

Cross-Functional Collaboration

• Coordinate with Implementation, Client Liaison, Treatment Navigation, Prior Authorization, Specialty Pharmacy Operations, Billing, Reimbursement, IT, Ascend, and Leadership teams to ensure timely and accurate resolution of member concerns.
• Facilitate communication between departments to ensure timely and accurate resolution of member concerns.
• Collaborate with providers, payers, manufacturers, and external partners when necessary.
• Build strong working relationships throughout the organization to improve issue resolution effectiveness and accountability.

Communication & Member Advocacy

• Clearly explain complex pharmacy, reimbursement, insurance, and operational processes to members and stakeholders.
• Provide professional, empathetic, and timely updates throughout the resolution process.
• Communicate findings, action plans, and required next steps in a manner that is clear, concise, and actionable.
• Advocate for the member while balancing regulatory, contractual, and organizational requirements.
• Maintain detailed documentation of all research, communications, actions, and outcomes.
• Deliver service recovery efforts when the member experience has not met organizational expectations.

Process Improvement

• Identify opportunities to improve workflows and reduce recurring member issues.
• Recommend corrective actions and process enhancements based on issue trend analysis and root cause findings.
• Partner with operational leaders to address systemic problems impacting member experience.
• Assist in developing standard operating procedures, training materials, and knowledge resources.
• Support initiatives focused on operational excellence, service quality, and member satisfaction.

Who You'll Be Working With

This position reports to the Manager of Operations and supports organizational goals related to service excellence, member experience, and operational efficiency.

The Member Resolution Expert reports directly to the Manager of Operations and works collaboratively with leaders and team members across Implementation, Client Liaison, Treatment Navigation, Prior Authorization, Specialty Pharmacy Operations, Billing, Reimbursement, Information Technology, Ascend, and Leadership teams.

The Member Resolution Expert serves as a central operational resource responsible for coordinating resolution activities across departments, ensuring accountability, facilitating communication, and driving timely resolution of complex member issues.

Skills and Experience You'll Bring to the Table

Required

• Associate degree or equivalent combination of education and experience; Bachelor's degree preferred.
• Three (3) or more years of experience in healthcare operations, specialty pharmacy, infusion pharmacy, reimbursement, patient support, customer service, care coordination, or a related healthcare environment.
• Demonstrated experience investigating and resolving complex customer, patient, or operational issues.
• Strong analytical, investigative, and problem-solving skills.
• Excellent written, verbal, and interpersonal communication skills.
• Ability to effectively manage multiple priorities and cases simultaneously.
• Proficiency in Microsoft Office applications, including Outlook, Excel, Word, and Teams.

Preferred

• Specialty pharmacy or infusion pharmacy experience.
• Knowledge of pharmacy and medical benefit reimbursement processes.
• Experience with pharmacy management systems, CRM platforms, electronic health records (EHR), claims systems, and patient management tools.
• Understanding of prior authorization, benefits investigation, claims adjudication, and billing workflows.
• Experience working within highly regulated healthcare environments.

Competencies You'll Bring to the Table

Systems Knowledge

• Ability to navigate and research information across multiple pharmacy, reimbursement, operational, and customer service platforms.
• Strong aptitude for learning new applications, workflows, and technologies.

Communication Excellence

• Outstanding verbal communication skills.
• Strong professional writing skills.
• Ability to translate complex operational and clinical information into clear, understandable communication.
• Skilled at presenting findings and recommendations to members, peers, and leadership.

Problem Solving

• Strong investigative and root-cause analysis capabilities.
• Ability to connect information from multiple sources to develop effective solutions.
• Sound judgment and decision-making skills in ambiguous situations.

Collaboration

• Works effectively across departments and organizational levels.
• Builds productive partnerships to drive issue resolution.
• Influences outcomes without direct authority.
• Demonstrates accountability and ownership.

Member Focus

• Demonstrates empathy, professionalism, and responsiveness.
• Maintains ownership of issues through final resolution.
• Committed to delivering an exceptional member experience.

Success Measures

• Member issue resolution turnaround time.
• Percentage of issues resolved within established service-level expectations.
• Member satisfaction and service recovery outcomes.
• Reduction in repeat member escalations.
• Accuracy and quality of issue documentation.
• Effectiveness of cross-functional coordination and resolution efforts.
• Identification and implementation of process improvements that reduce member friction and operational inefficiencies.

Work Environment:

Primarily office-based or remote work environment. Frequent interaction with members, providers, payers, and internal departments. Ability to manage sensitive and confidential information in accordance with HIPAA and organizational policies. May require participation in escalated issue reviews and operational improvement initiatives.

OptiMed Health Partners provides equal employment opportunities to all employees and applicants

for employment and prohibits discrimination and harassment of any type without regard to race,

color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual

orientation, gender identity or expression, or any other characteristic protected by federal, state or

local laws.

This policy applies to all terms and conditions of employment, including recruiting, hiring,

placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and

training.