• Resolve member complaints and escalated issues, ensuring a satisfactory outcome. • Document and track escalated issues, maintaining clear and comprehensive records from initiation to resolution. • Manage casework queues in Customer Relationship Management tool (Microsoft Dynamics). • Research account history, notes, treatment plans and settlement documents to identify escalation root cause and devise positive outcomes. • Consult with various departments including Claims, Rx and Sales to gather information and coordinate efforts in devising effective solutions. • Manage inbound call volume. • Outreach to providers, pharmacies, and members to obtain additional information as needed. • Develop and implement strategies to reduce the volume of escalated issues by identifying drivers, patterns, and trends. • Demonstrate proficiency in problem-solving and thinking critically when it comes to resolving member complaints. • Communicate effectively with members, internal teams, and management. • Ability to explain coverage determinations. • Identify and recommend ways in which our Member Care team can further build connections through empowerment and ownership. • Ensure familiarity with the most up-to-date policies and procedures and recognize potential additions or modifications as needed. • Share opportunities for learning and development on member issues and potential improvements based on trend analysis with management and other team members.