Ombudsman Services Specialist
About The Position
The Ombudsman Services Specialist supports members by evaluating and resolving concerns related to benefits administered by ETF. This includes health insurance, life insurance, income continuation insurance, disability programs, and Wisconsin Retirement System (WRS) benefits. The role requires independent decision‑making, strong analytical skills, and the ability to interpret complex benefit policies and regulations. The Specialist frequently serves as an advocate for participants, working with insurance plans, third‑party administrators, and ETF staff to resolve disputes. When a complaint cannot be fully resolved, the Specialist provides guidance on next steps and available options.
Requirements
- Knowledge of health insurance, life insurance, income continuation insurance, and WRS benefit programs.
- Understanding of state and federal laws, rules, and regulations governing Medicare and Medicare supplement programs.
- Ability to independently prioritize workload and make sound decisions after training.
- Proficient use of computer applications for letters, spreadsheets, and reports.
- Effective written and verbal communication skills.
- Strong human relations skills and professional customer service aptitude.
- Knowledge of public relations and public speaking fundamentals.
- Skill in negotiation, advocacy, and complaint‑resolution techniques.
- Knowledge of interviewing, investigation, research, and data analysis methods.
- Ability to gather, track, and interpret statistical information.
- Understanding of information systems, data processing, and quality improvement methodologies.
- Ability to design and deliver educational materials and training sessions.
- Familiarity with health care delivery systems and benefit plan grievance/appeal processes.
Responsibilities
- Review, investigate, and resolve benefit‑related complaints and inquiries from WRS participants.
- Negotiate changes in benefit interpretations, policies, or practices with insurance plans and administrators.
- Advise participants on grievance, appeals, and dispute‑resolution options when issues remain unresolved.
- Research and interpret applicable state and federal regulations, including Medicare and Medicare supplement rules.
- Prepare written summaries, reports, letters, and educational materials.
- Conduct interviews, gather data, and analyze information relevant to participant concerns.
- Deliver training and educational support on benefit programs when needed.
- Collaborate with internal ETF teams to address systemic issues or recurring participant concerns.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Education Level
No Education Listed
