Appeals & Grievances Specialist

Respond to written/verbal grievances, complaints, appeals and disputes submitted by members and providers in accordance with state and other regulations.  Types of correspondence handled by the individual will include but are not limited to, correspondence, payment disputes, complaints/grievances, and appeals. Work requires exercising considerable independent judgment and initiative in performing case file investigation.  The financial consequences of an error could be significant.  Position requires extensive knowledge and experience in claims, enrollment, benefits and member contracts.

Responsibilities:
Provide written acknowledgment of all member and provider correspondence.
Independently review all receipts; interpret regulations and appropriately classify the inquiry according to internal and regulatory timelines.
Make critical decisions regarding research and investigation to appropriately categorize and resolve all inquiries.
Independently conduct thorough investigations of all member and provider correspondence by analyzing all the issues involved and obtaining responses and information from internal and external entities.
Ensure internal and regulatory timeframes are met.
Accurately and completely investigate the cases presented by members and providers.
Investigate and identify root cause analysis, document, and present to management.
Provide recommendations to management regarding issues resolution and best practices.
Prepare written responses to all member and provider correspondence that appropriately addresses each complainant’s issues and are structurally accurate.
Monitor daily and weekly pending reports
Liaise with Claims to ensure determinations are effectuated within stringent timeframes.
Accurately and completely prepare cases for medical and administrative review detailing the findings of their investigation for consideration in the plan’s determination.
Regular attendance is an essential function of the job.  Performs other duties as assigned or required.

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