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JOB SUMMARY

The Appeals and Grievance Specialist performs reviews, within operational aspects, of the member and provider complaints, appeals and grievance cases for products for all lines of business. Responsibilities include, but are not limited to: timely classification and resolution of cases; review, research and coordination of complaints, grievances, appeals and reconsiderations consistent with statutory and federal regulatory guidelines.

ESSENTIAL FUNCTIONS OF THE ROLE

Maintains data entry requirements for all complaints, appeals and grievances.

Builds case files for each complaint, appeal and grievance, and ensures compliance with organizational and regulatory guidelines.

Investigates providers and members or authorized representatives concerns and disputes for all lines of business. Contacts members and providers to gather information and communicate disposition of cases. Consults with health care providers, vendors, legal representatives, medical, and staff administration, and accurately documents all communication with involved parties. Reviews details submitted by members and providers; verifies classifications and enters information into the data management tracking system.

Maintains case assignment worklist assuring cases are on track and closed within the regualtory turn around time.

Coordinates activities for all expedited and external case reviews, and prepares final case submissions.

Refers clinical appeal cases to Medical Nurse Auditors or Pharmacy Technicians for handling where required.

Ensures case closure correspondence is generated in accordance with regulatory and statutory requirements and in response to instructions from external review entities.

Chairs and coordinates participation at appeal panel hearings, e.g. coordinates with members of panel, provides information prior to hearing, assures scheduling and physician follow-up to ensure attendance, as appropriate.

KEY SUCCESS FACTORS

Bachelor's degree in Healthcare, Administration, or related field preferred.

Must possess strong organizational, logical reasoning, ability to analyze information, and problem-solving skills, with attention to detail necessary to act within complex environment.

Advanced oral and written communication ability required.

Proficiency in Microsoft Office and Access.

Ability to appropriately identify urgent situations and follow the appropriate protocol.

Requires the ability to plan and manage multiple priorities within a fast-paced office environment.

Must be able to work well independently and as a team member.

Knowledge of basic medical terminology a plus.

BENEFITS

Our competitive benefits package includes the following
- Immediate eligibility for health and welfare benefits
- 401(k) savings plan with dollar-for-dollar match up to 5%
- Tuition Reimbursement
- PTO accrual beginning Day 1
Note: Benefits may vary based upon position type and/or level

QUALIFICATIONS

- EDUCATION - Bachelor's or 4 years of work experience above the minimum qualification

- MAJOR - Healthcare

- EXPERIENCE - 2 Years of Experience

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