Vacancy expired!
Grievance & Appeals Representative II- Remote (Western USA)- PS30171Location: United StatesNewRequisition #: PS30171Grievance/Appeals Representative IIResponsible for reviewing, analyzing and processing policies related to claims events to determine the extent of the company's liability and entitlement. Primary duties may include, but are not limited to:
Conducts investigation and review of customer grievances and appeals involving provision of service and benefit coverage issues.
Contacts customers to gather information and communicate disposition of case; documents interactions.
Generates written correspondence to customers such as members, providers and regulatory agencies.
Researches administrative or non-clinical aspects of the appeal, e.g. eligibility, benefit levels, overall adherence to policies and practices.
May make decision on administrative appeals where guidelines are well documented and involve limited discretion.
Prepares files for internal or external review by analysts, medical staff or outside consultant.
Triages clinical and non-clinical inquiries, grievances and appeals, prepares case files for member grievance committees/hearings.
Summarizes and presents essential information for the clinical specialist or medical director and legal counsel.
Requirements
High School diploma or equivalent;
1-4 years experience in customer service, preferably in a managed care environment, medical office, or health insurance;
or any combination of education and experience, which would provide an equivalent background.
Ability to organize work, set and manage multiple priorities in a time sensitive manner.
Basic word processing, data base management, and spreadsheet skills required.
PC proficiency.
Claims knowledge is helpful.
Good oral and written communication skills.
An Equal Opportunity Employer/Disability/Veteran
Vacancy expired!