Your Work
In this role, you will:
- Answer telephone inquiries regarding member appeals.
- Respond to appeals and grievances and member reconsiderations.
- Research, review and resolve high level/high priority member grievances, appeals and complaints, while clarifying issues and educating customers in the process.
- Interpret and explain health plan benefits, policies, procedures and functions to members and providers.
- Administer ongoing grievance tracking, trending, and reporting for assigned grievances.
- Review incoming appeals and grievances and determine which area to assign case to or reroute if the issue does not meet appeal or grievance criteria.
- Work in a collaborative manner with your team to meet compliance timeframes.
- Manage your time independently to ensure that all job duties are completed in a timely manner.
Your Work
In this role, you will:
- Answer telephone inquiries regarding member appeals.
- Respond to appeals and grievances and member reconsiderations.
- Research, review and resolve high level/high priority member grievances, appeals and complaints, while clarifying issues and educating customers in the process.
- Interpret and explain health plan benefits, policies, procedures and functions to members and providers.
- Administer ongoing grievance tracking, trending, and reporting for assigned grievances.
- Review incoming appeals and grievances and determine which area to assign case to or reroute if the issue does not meet appeal or grievance criteria.
- Work in a collaborative manner with your team to meet compliance timeframes.
- Manage your time independently to ensure that all job duties are completed in a timely manner.
Your Knowledge and Experience
- Requires a high school diploma or GED
- Requires at least 2 years in health insurance operations such as I&B, Claims, Customer Services, Regulatory Affairs and/or Appeals/Grievances or similar combination
- Commercial/IFP health plan knowledge preferred
- Requires knowledge of Microsoft Systems such as Power Point, Excel, and Word