Appeals and Grievance Intake

The Appeals and Grievance Coordinator researches complex issues pertaining to the caller’s health, status and potential plan options. This position is responsible for enrollment, billing activities and/or maintaining assigned accounts and requires the incumbent to navigate across multiple databases. Requires fluency in computer navigation and toggling while confidently and compassionately engaging with the caller.

ESSENTIAL DUTIES AND RESPONSIBILITIES

1. Coordinates the intake of appeal and grievances requests from members and providers into the designated systems.
2. Generates Acknowledgement Letters to mail to appellants and answering general appeal status questions.
3. Compiles case files to be sent to Independent Review Entity (IRE).
4. Ensures adherence with state and federal regulatory timeframes for handling cases including acknowledging cases, resolving cases, monitoring effectuation of resolution, completing resolution letters and communicating with members and providers within required timeframes.
5. Prepares case files for Independent Review Entities or other escalated types of cases, including documentation of the Statement of Position and case narratives.
6. Develops Grievance and Appeal request information from designated databases.
7. Assists Investigation and Appeals Specialists with appeal and grievance resolutions.
8. Develops and maintains positive customer relations and coordinates with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner

QUALIFICATIONS

• Exceptional problem solving skills.
• Must be able to effectively communicate verbally.
• Computer Skills: Proficient in Microsoft Office Applications. Familiarity with medical terminology, health plan documents, or benefit plan design
• Experience working with vulnerable populations
• Demonstrated ability to quickly build rapport and respond to customers in a compassionate manner by identifying and exceeding customer expectations (responding in respectful, timely manner, consistently meeting commitments)

WORK EXPERIENCE

Two (2) years experience working in a managed care environment in grievance or appeals, claims or related experience. Or Equivalent Combination of Training and Experience

LANGUAGE SKILLS

Bilingual English/Spanish fluency.