Summary
The Sr. Executive Response Specialist supports, researches, and responds on behalf of G.E.H.A's Leadership Team to manage complex medical and dental issues that have been escalated to G.E.H.A’s Senior Leadership Team, OPM, compliance, among others. The Executive Response Specialist is responsible for the end-to-end handling of the escalations, including but not limited to partnering with internal and external subject matter experts to research the member or provider’s concerns, perform root cause analyses, and communicate with the members and providers.
The ideal candidate is a meticulous problem-solver and skilled communicator who thrives under pressure and consistently demonstrates professionalism and discretion. They are passionate about member advocacy, confident in navigating ambiguity, and adept at investigating and troubleshooting when information is incomplete. This role requires exceptional written and verbal communication skills, as well as the ability to collaborate across multiple teams while maintaining a relentless focus on delivering respectful and timely communication to key stakeholders.
Duties
- Responsible for handling medical and dental escalations submitted to the Executive Escalations team, including but not limited to:
- Tracking and reporting on all issues.
- Researching the member’s medical or dental claims history, call transcripts, and eligibility records, to identify any issues or errors that need to be resolved. This includes a detailed review of the claims processing.
- Working with internal and external subject matter experts to oversee resolution, as appropriate
- Communicating directly with the member and/or provider via email and/or phone to ensure incremental updates are communicated.
- Communicating directly with the member, provider, and/or and final resolution is communicated.
- Responds on behalf of G.E.H.A's Leadership team, and other key stakeholders to manage complex and high-profile medical and dental escalations including OPM grievances.
- Conducts investigative research including auditing phone calls, emails, claims processing, and process flows to determine root cause.
- Highlights breakdown points in the customer journey and processes; consults with stakeholders on opportunities for improvement and/or trends.
- Partners with internal and external partners to support efforts to improve customer experience and claims processing accuracy.
- Identify areas of potential improvement to internal processes that directly impact the accuracy and speed of claims processing and associated functions.
- Coordinate and lead working meetings with cross-functional teams to review complex escalations.
- Requires a powerful sense of accountability and end-to-end ownership to ensure all escalations are resolved quickly and accurately.
- Supports projects/other duties as assigned.
Education Requirements
Requires a Bachelor’s degree in a related field, additional years of qualifying work experience may be considered in lieu of formal education.
Experience Requirements
- Requires a minimum of 6 years’ experience at a medical or dental insurance plan, that includes at least 3 years of senior claims processing experience, with a comprehensive understanding of the adjudication process for medical and/or dental claims.
- Requires knowledge of medical terminology, medical codes, and related reference materials.
- Experience creating collaborative and productive relationships with internal and/or external partners.
- Attention to detail with the capacity to manage multiple complex issues and deadlines effectively.
- Excellent problem solving, critical thinking, and analytic skills.
- Requires strong verbal and written communication skills and proficiency in all channels of communication at levels of the organization and with external partners.
- Demonstrates a strong understanding of reputational risk and public perception when managing member complaints.
- The ability to summarize present data and findings in MS Excel, PowerPoint, or Power BI.
- Must be able to work independently.
Preferred Qualifications
- Experience with Federal Employees Health Benefits Program (FEHBP) or Federal Employees Dental and Vision Program (FEDVIP).
- Customer Service experience.
- Candidate must reside in Kansas City Metro.
GEHA is an Equal Opportunity Employer, which means we will not discriminate against any individual based on sex, race, color, national origin, disability, religion, age, military status, genetic information, veteran status, pregnancy, marital status, gender identity, and sexual orientation, as well as all other characteristics and qualities protected by federal, state, or local law. We celebrate diversity and are committed to creating an inclusive environment for all employees.
