Investigate, document, and resolve complex member and provider complaints; perform root-cause analysis; ensure compliant resolutions per HIPAA, CMS, and TDI; document actions in CRM; follow up with members and collaborate with Legal, QA, and Operations to address systemic issues.
Harbor Health
Contact Center Escalation Specialist
Texas Markets | Contact Center Operations | Full-Time
POSITION OVERVIEW
Harbor Health is seeking a Contact Center Escalation Specialist to investigate, document, and resolve complex member and provider complaints within our contact center. This role requires strong analytical skills, deep knowledge of health insurance processes, and a commitment to delivering thorough, compliant resolutions. You will collaborate closely with Legal, QA, and Operations teams to address systemic issues and ensure outstanding member outcomes — serving as a trusted advocate for members and a key driver of service quality that aligns with our mission of transforming healthcare through our payvider model.
POSITION DUTIES & RESPONSIBILITIES
- Conduct research and analysis of incoming member and provider complaints to determine root causes and appropriate corrective actions
- Implement resolution strategies for complex member issues, ensuring consistent and compliant outcomes in line with Harbor Health policies and regulatory requirements
- Document all complaint details, investigation steps, resolutions, and follow-up activities with meticulous accuracy in the designated tracking system
- Ensure complaint handling procedures and resolutions adhere to internal policies and applicable regulations, including HIPAA, CMS, and TDI
- Execute timely, proactive follow-up with members and internal stakeholders to confirm resolution satisfaction and mitigate recurrence or further escalation
- Collaborate cross-functionally with Legal, Quality Assurance, and Operations to address systemic issues identified through the complaints process
DESIRED PROFESSIONAL SKILLS & EXPERIENCE
Required:
- 1–2 years of experience in member services or provider services within a healthcare environment
- Comprehensive understanding of health insurance plan processes: claims, appeals, grievances, and prior authorizations
- Proficiency in healthcare compliance standards and internal policies related to complaint management, including HIPAA, CMS, and TDI
- Proven experience with compliance procedures and medical group plan operations
- Exceptional written and verbal communication skills; ability to manage sensitive member issues with professionalism
- Strong research, analysis, and problem-solving skills to identify root causes and implement effective resolutions
- Competency maintaining records in CRM or complaint management software
- Ability to collaborate effectively with Legal, QA, and Operations teams
Preferred:
- Prior experience in a primary care or value-based care setting
- Familiarity with payvider, ACO, or managed Medicaid/Medicare environments
- Experience with Athena or similar EHR/practice management systems
- Bilingual in English/Spanish
- Understanding of HEDIS or Star Ratings quality measures
WHAT WE OFFER
- Competitive salary and incentives
- Generous PTO
- 10 paid holidays
- Medical, Dental, and Vision Insurance
- 401(k) Investment Plan
- Company Equity
- Professional development and growth opportunities as the team scales
At Harbor Health, we're transforming healthcare in Texas through collaboration and innovation. We're seeking passionate individuals to help us create a member-centered experience that connects comprehensive care with a modern payment model. If you're ready to make a meaningful impact in a dynamic environment where your contributions are valued, please bring your talents to our team!
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