Job Description

Would you like to join a dynamic team dedicated to improving the lives of the people we come in contact with?  Are you sensitive to the needs of the elderly?  

We are seeking Grievance and Appeals Specialists that meet the following requirements:

 

  • Analyze and resolve verbal and written claims, medical pre-service appeals, Part D pre-service appeals from both providers and members.
  • Analyze and resolve verbal and written grievances and CTMs from members and legal representatives.
  • Intake verbal grievance and appeals requests from Member Services and/or other departments and migrate to the organization’s Appeals & Grievance system for tracking and processing.
  • Resolve all State inquires related to complaints, grievances and appeals.
  • Adhere to all federal, state and organizational regulations and policies and procedures pertinent to the review and processing of member and provider grievances and appeals.
  • Prepare cases for medical review as necessary.
  • Review grievances to identify potential quality or access issue and escalate for clinical review.
  • Draft and mail all provider and member grievance and appeals-related communications within the timeframes required by State and Federal agencies.
  • Conduct outreach to members and providers for additional information required to resolve grievance and appeals cases. This may involve placing outbound calls or sending faxes or e-mails.
  • Provide members and/or providers with status updates, upon request, regarding their open grievances or appeals
  • Collaborate with subject matter experts within the organization to obtain benefit and/or clinical opinions/interpretations of complex cases.
  • Serve as liaison between member, provider regulatory agencies and internal staff.
  • Correspond with key individuals regarding grievance and appeal decisions.
  • Act as subject matter expert regarding grievances and appeals.

Requirements 

  • Excellent written and oral communication skills
  • Ability to mult-task accurately and efficiently
  • Maintain production and accuracy standards
  • Strong analytical
  • Associate’s degree in related field or equivalent experience.
  • 2 years of claims, contracting, or related experience in a managed care environment (preferably Medicare Advantage).