Customer Advocacy Specialist - Escalations and Complaints

As a Customer Advocacy Specialist at Wellmark, you will be the trusted voice for our members. In this role, you’ll advocate on behalf of customers by coordinating, researching, and resolving complaints, live escalations, and service experience or disruption reviews in alignment with state, federal, and Wellmark guidelines. You will communicate resolutions directly to customers with clarity and empathy, while also helping them understand their products, benefits, and the tools available to support them. Success in this role comes from your ability to look beyond the issue at hand. You will partner with business areas across the organization to address concerns and deliver timely, accurate solutions, while also providing valuable feedback on how complaints and inquiries are handled. Your insights will help identify opportunities to improve the overall service experience, ensuring that members feel supported and confident in the care and resources they receive. This is more than a problem-solving position — it’s a chance to make a meaningful impact on the customer journey. By serving as both an advocate and an educator, you will help strengthen relationships with our members and influence improvements that shape the way we deliver service at Wellmark. Required: High School Diploma or GED 3+ years of experience in health insurance operations OR 4+ years of experience handling customer complaints/inquiries in a highly regulated industry Understanding and/or application of relevant regulations and business rules required to perform the role Excellent verbal and written communication skills; develops and maintains strong relationships with clients (Wellmark members/ groups, internal stakeholders and external stakeholders) by listening to the client/customer and understanding and responding to identified needs Strong de-escalation skills; effectively resolves issues and conflicts in a professional manner while maintaining composure and confidence. Displays empathy and discerns stakeholders’ true intent Exceptional organization skills, time management and attention to detail Strong business knowledge and perspective; ability to synthesize complex information and develop theories to arrive at logical recommendations Experience compiling and analyzing data for the purpose of telling a story with the data/metrics Ability to research and use appropriate interaction skills and methods to guide individuals or groups to accomplish work, reach consensus, or take action Ability to measure and evaluate work processes, and utilize appropriate resources to identify next steps, potential impacts/risks, and solutions Knowledge of electronic systems such as Microsoft applications, email, internet and other on-line tools Travel required up to 5% Preferred: Associate’s degree a. Coordinate, research and resolve customer complaints, including live escalations and service experience and disruption reviews. Be an advocate for the customer and seek to understand customer complaints and provide education when appropriate. b. Review and analyze customer feedback and data, including processes across the company where customers have a chance to experience disruption, and identify and recommend areas for improvement. c. Ensure customer complaint resolution within appropriate timeframes set forth by corporate and governmental guidelines. Communicate (typically via phone and/or written letter) and confirm resolution with the customer and ensure customers are educated and understand their products, benefits, tools and how to use them. As needed, adjust and process claims to complete resolution of customer complaints with Customer Advocacy Specialist II partnership. d. Ensure all documentation regarding complaints are thorough and routed to the appropriate support areas for further investigation and resolution. May draft a variety of written communications regarding complaint updates, education and resolution. e. Successfully develop and maintain team member relationships through positive interactions. Will partner and collaborate with other business areas, such as Appeals, Legal, Compliance, Health Services, Network Engagement and Sales to ensure appropriate complaint resolution. f. Provide feedback to Customer Service team leaders and other areas of the business regarding complaints, escalations and service experience & disruption. g. As needed, provide complaint reports to various business areas (i.e., complaint reports for account team or claim summary reports) for trend analysis. h. Maintain knowledge of healthcare guidelines and policies, contracts, standard operating procedures, and other Federal regulations as well as Corporate and Departmental guidelines affecting the complaint process. i. Perform outreach calls to members and providers relating to health benefits, claims processing/payment and other complaints. j. Identify and make recommendations for training and educational opportunities for Wellmark internal staff, including but not limited to Knowledge Article updates, Voice of the Customer or huddle announcements, etc. k. Identify and make recommendations for process improvement through research and analysis and proactively provide possible solution recommendations. l. Provide back up support as needed to HICS case processing. m. Other duties as assigned. An Equal Opportunity Employer The policy of Wellmark Blue Cross Blue Shield is to recruit, hire, train and promote individuals in all job classifications without regard to race, color, religion, sex, national origin, age, veteran status, disability, sexual orientation, gender identity or any other characteristic protected by law. Applicants requiring a reasonable accommodation due to a disability at any stage of the employment application process should contact us at [email protected] Please inform us if you meet the definition of a " Covered DoD official ". At this time, Wellmark is not considering applicants for this position that require any type of immigration sponsorship (additional work authorization or permanent work authorization) now or in the future to work in the United States. This includes, but IS NOT LIMITED TO: F1-OPT, F1-CPT, H-1B, TN, L-1, J-1, etc. For additional information around work authorization needs please refer to the following resources: Nonimmigrant Workers and Green Card for Employment-Based Immigrants Wellmark supports and expects the responsible use of AI for our workforce! We welcome the responsible use of these tools by job seekers as well and are interested in learning from you; you will have an opportunity in the application process to share which tools you used and how you applied them.