Member Service Guide, Complaint Resolution

A Bit About This Role

As a Member Service Guide II, Complaint Resolution at Devoted Health, you will play a vital role in resolving member grievances with accuracy, efficiency, and compassion. You'll ensure cases are handled in compliance with regulatory requirements and within established timeframes, while also helping build trust with our members. This role requires strong attention to detail, excellent communication skills, and the ability to work across teams to ensure grievances are resolved fairly and thoroughly.

This position is ideal for someone who is detail-oriented, empathetic, and committed to both regulatory compliance and delivering an exceptional member experience. You will uncover what members really need, recommend solutions that make things easier for them, help identify opportunities for process improvements, strengthen member relationships, and contribute to Devoted's mission of caring for every person like family.

Responsibilities and Impact Will Include

• Maintain up-to-date knowledge of Devoted Health products, benefits, policies, and procedures
• Support a culture of continuous learning and member advocacy, helping Devoted fulfill its mission
• Conduct thorough investigations by reviewing case details, member records, and relevant policies and procedures to identify the root cause of member needs
• Independently resolve the majority of grievances, analyzing information across systems to determine appropriate solutions
• Recommend clear, practical solutions that address the root cause and minimize member effort, connecting members to Devoted programs and resources when appropriate
• Use sound judgment to escalate more complex situations when additional expertise is required
• Effectively triage work to ensure grievances are accurately categorized and routed
• Communicate with members through both written correspondence and telephone contact, meeting all regulatory requirements while fostering trust
• Adapt tone, pacing, and explanation to member needs, proactively clarify information, and confirm next steps
• Complete accurate documentation and data entry across multiple systems
• Ensure all grievances are resolved within required regulatory and departmental timelines
• Independently manage workload, adjust priorities based on volume and complexity, and flag capacity constraints or competing priorities early
• Collaborate with internal partners and teammates to gather information, resolve cases thoroughly, and share knowledge that helps peers improve
• Contribute to identifying themes and opportunities for improvement in processes or member experience
• Actively seek feedback, apply it consistently, and adjust quickly to changes in workflows, tools, or priorities
• Flex into other teams' work for short periods during non-peak volume as business priorities evolve.

Required Skills and Experience

• Experience with Medicare Advantage appeals and grievances
• Strong attention to detail and commitment to data accuracy
• Adaptability: Handles changing regulations, priorities, or case volumes with resilience and teamwork
• Excellent customer service and conflict resolution skills, particularly when interacting with members who may be frustrated or vulnerable
• Strong time management and organizational skills, with the ability to meet deadlines consistently
• Ability to work both independently and as part of a collaborative team
• Strong written and verbal communication skills, with the ability to clearly and concisely explain complex information
• Ability to obtain and maintain access to the CMS Health Plan Management System (HPMS), including completing any required access, security, and training steps.

Desired Skills and Experience

• Bachelor's degree or equivalent experience in healthcare, conflict resolution, or related field
• Working knowledge of insurance products, policies, procedures, and claims processes
• Superior investigative, analytical, and problem-solving skills
• Experience escalating cases and collaborating with internal stakeholders when additional support is needed
• Strong computer and documentation skills, with comfort using multiple platforms

Hours of Operation & Scheduling Expectations

• This is a five-day-a-week role. Our hours of operation are 8:00 AM - 2 AM ET, Monday through Friday. Your shift will be 8.5 hours, including a 30-minute lunch, and will fall within this window.
• This role may include weekend coverage on a rotating basis, up to one weekend per month. Schedules are subject to change based on business needs, including weekend on-call support.

Salary range

$22.00 - $25.00 hourly

The pay range listed for this position is the range the organization reasonably and in good faith expects to pay for this position at the time of the posting. Once the interview process begins, your talent partner will provide additional information on the compensation for the role, along with additional information on our total rewards package.

The actual base salary offered will depend on a variety of factors, including the qualifications of the individual applicant for the position, years of relevant experience, specific and unique skills, level of education attained, certifications or other professional licenses held, and the location in which the applicant lives and/or from which they will be performing the job.

Our Total Rewards package includes

• Employer sponsored health, dental and vision plan with low or no premium
• Generous paid time off
• $100 monthly mobile or internet stipend
• Stock options for all employees
• Bonus eligibility for all roles excluding Director and above; Commission eligibility for Sales roles
• Parental leave program
• 401K program
• And more....

*Our total rewards package is for full time employees only. Intern and Contract positions are not eligible.

Founded in 2017, Devoted Health is on a mission to dramatically improve the health and well-being of older Americans by caring for everyone like they are family, and that includes our employees. Our robust and seamlessly integrated care platform merges advanced data and AI access with world-class clinical and service experiences to create a member experience that is unlike the industry norm.

To continue building upon our mission, we want to bring together those who share our values, embrace change and advancement, and are enthusiastic about where we're going - all the while bringing their own unique qualities, experiences, and expertise, in hopes of further changing the healthcare experience.

• We are committed to a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the business.
• We value diversity and collaboration.
• Individuals are respected for their skills, experience, and unique perspectives.
• This commitment is embodied in Devoted's Code of Conduct, our company values and the way we do business.