Member Service Guide, Complaint Resolution in New York at Jobgether

This position is listed on behalf of a partner company, which manages all applications and next steps. Our partner is looking for a Member Service Guide, Complaint Resolution based in the United States.

In this role, you will play an essential part in ensuring that members receive fair, timely, and compassionate resolutions to their grievances. You will investigate complaints, identify underlying issues, and recommend practical solutions that improve the overall member experience. Working across multiple systems and collaborating with internal teams, you will ensure that every case is handled accurately and in accordance with regulatory requirements. You will have the opportunity to build meaningful relationships with members, particularly those navigating challenging healthcare situations. Your work will contribute to strengthening trust, improving service quality, and identifying opportunities for continuous improvement. This position is ideal for a detail-oriented and empathetic professional who combines strong investigative skills with a passion for member advocacy.

• Investigate and resolve member grievances by reviewing case information, member records, and relevant policies to identify root causes and determine appropriate solutions.
• Independently manage and resolve most complaints, ensuring fair, accurate, and timely outcomes in compliance with regulatory requirements.
• Maintain up-to-date knowledge of healthcare products, insurance benefits, policies, procedures, and available member support resources.
• Communicate with members through telephone calls and written correspondence, adapting communication styles to individual needs and ensuring clear explanations of decisions and next steps.
• Identify appropriate solutions that address members' concerns while minimizing their effort and connecting them with relevant programs and resources when necessary.
• Escalate complex or sensitive cases to the appropriate internal teams when additional expertise or support is required.
• Accurately categorize, prioritize, and route grievances while maintaining comprehensive documentation across multiple systems.
• Manage individual workloads effectively, balancing case volume, complexity, and regulatory deadlines while proactively communicating capacity constraints.
• Collaborate with colleagues and internal stakeholders to gather information, resolve cases, share knowledge, and support consistent service delivery.
• Identify recurring complaint trends and recommend improvements to processes, workflows, and the overall member experience.
• Apply feedback, adapt to evolving procedures and tools, and contribute to a culture of continuous learning and member advocacy.
• Provide temporary support to other teams when operational priorities or business needs require additional flexibility.

• Previous experience handling Medicare Advantage appeals and grievances is required.
• Strong attention to detail, with a demonstrated commitment to accuracy, thorough documentation, and data integrity.
• Excellent customer service, communication, and conflict resolution skills, particularly when supporting frustrated or vulnerable members.
• Strong investigative, analytical, and problem-solving abilities, with the capacity to assess complex situations and identify appropriate resolutions.
• Excellent written and verbal communication skills, including the ability to explain complex healthcare information clearly and empathetically.
• Strong organizational and time management skills, with the ability to manage multiple cases, prioritize competing demands, and consistently meet deadlines.
• Adaptability and resilience when responding to changing regulations, workflows, priorities, and case volumes.
• Ability to work independently while contributing effectively to a collaborative, cross-functional environment.
• Ability to obtain and maintain access to the CMS Health Plan Management System (HPMS), including completing all required access, security, and training procedures.
• A bachelor's degree or equivalent professional experience in healthcare, conflict resolution, or a related field is preferred.
• Working knowledge of healthcare insurance products, policies, procedures, and claims processes is an advantage.
• Experience escalating complex cases and collaborating with internal stakeholders to achieve appropriate outcomes is desirable.
• Strong computer literacy, documentation skills, and confidence navigating multiple digital platforms are preferred.

• Salary: $22.00–$25.00 per hour, depending on qualifications, relevant experience, education, certifications, skills, and work location.
• Work arrangement: Fully remote position within the United States.
• Working schedule: Five days per week, with 8.5-hour shifts, including a 30-minute lunch break.
• Operating hours: Shifts are scheduled within the Monday-to-Friday operating window of 8:00 AM to 2:00 AM Eastern Time.
• Weekend coverage: Rotating weekend coverage may be required, up to one weekend per month, with schedules subject to business needs and potential weekend on-call support.
• Healthcare coverage: Employer-sponsored medical, dental, and vision insurance plans with low or no employee premiums.
• Paid time off: Generous paid leave.
• Monthly stipend: $100 allowance for mobile phone or internet expenses.
• Equity: Stock options available to all employees.
• Bonus opportunities: Bonus eligibility for applicable roles, excluding Director-level positions and above.
• Parental support: Parental leave program.
• Retirement planning: 401(k) program.
• Additional rewards: Access to further employee benefits and rewards as part of the total compensation package.