**Key Responsibilities**

+ Responsible for case development and resolution of non-clinical cases, such as: certain types of claim denials, member complaints, and member and provider appeals. The end-to-end process requires the Specialist to independently:
+ Research issues
+ Reference and understand HFs internal health plans policies and procedures to frame decisions
+ Interpret regulations
+ Resolve cases and make critical decisions
+ Edit and finalize resolution letters
+ Manage all duties within regulatory timeframes
+ Communicate effectively to hand-off or pick-up work from colleagues
+ Work within a framework that measures productivity and quality for each Specialist against expectations
+ Work independently exercising judgment starting the case development with the respective internal and external entities in the timeframe prescribed in the Job Aid and/or regulatory timeframes.
+ Prepare and submit well documented appeals in accordance with ...