Escalation Specialist

Position Overview

The Contact Center Escalation Specialist is responsible for investigating, documenting, and resolving complex member and provider complaints within Harbor Health‘s contact center.

This role requires strong analytical skills, deep knowledge of health insurance processes, and a commitment to delivering thorough, compliant resolutions. The Escalation Specialist collaborates closely with Legal, QA, and Operations teams to address systemic issues and ensure outstanding member outcomes.

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 (HIPAA, CMS, 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 (HIPAA, CMS, TDI)
• Proven experience with compliance procedures and medical group plan operations
• Exceptional written and verbal communication; 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: English / Spanish
• Understanding of HEDIS or Star Ratings quality measures

What We Offer

• Opportunity to shape how Harbor Health resolves member issues and builds trust in a first-of-its-kind payvider model in Texas
• Collaborative and dynamic work environment where your effort and voice are visible
• An organization of people passionate about transforming healthcare for underserved communities
• Competitive salary and benefits package
• Professional development and growth opportunities as the team scales
• A transparent startup culture with direct access to leadership

Harbor Health is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, protected veteran status, or any other characteristic protected by law.

Originally posted on Himalayas