Health Pro

As a Health Pro, you can expect the following: When you start, you will receive extensive health care and case management training to ensure you are equipped to support members on complicated healthcare matters. Your primary responsibility is to be an advocate for members requiring guidance across the health benefits environment by helping them navigate questions about their benefits, identify the highest quality and cost-effective providers, understand benefit claims, and be an advocate for the employee across the health ecosystem. You will gather a full understanding of the members’ needs and own the resolution of the customer’s request. Activities include, but are not limited to the following: Gathering information about the reason the customer is seeking support or care; Educating members on benefit programs provided by clients; Translating complex benefit details (e.g., deductibles, coverage limits, prior authorizations) into clear, actionable guidance members can understand and use; Delivering provider recommendations, referral guidance, and connections to clinical or employer‑sponsored programs to support informed care decisions; Completing cost estimates and communicating out‑of‑pocket responsibility, claim results, denials, appeals, and escalation outcomes with accurate expectations and timelines; Explaining prescription formulary options, prescription alternatives, prior authorization outcomes, and available cost‑saving opportunities; Proactively identifying unmet clinical needs and owning the connection to appropriate clinical support and care resources; Connecting members to company sponsored health and benefits programs for specialized care; Providing proactive, timely updates via phone and digital channels and ensuring members feel supported through full case resolution; Navigating medical bill review results, including identified errors and savings achieved, and translating findings into clear, actionable guidance for members; Drafting carrier and client appeals for healthcare services; Coordinating records transfers and authorization requests that require pre-service approval.