GENERAL SUMMARY
Responsible for supervising the day-to-day grievance activities. Ensures compliance with all State regulations and national accrediting body requirements.
ESSENTIAL RESPONSIBILITIES
- Responsible for the direct supervision of the appeals staff.
- Responsible for compliance with State law regarding the handling of appeals. Ensures compliance with national accrediting body standards regarding grievances.
- Ensures compliance with the applicable accreditation agency’s standard section regarding member rights and responsibilities.
- Produces all appeals reports. Researches customer information in response to difficult inquiries, including authorizations, payments, denials, and coordination of benefits.
- Assesses, investigates, and resolves difficult issues to achieve customer satisfaction. Receives all legal correspondence that is not directed to any specific individual within the health plan.
- Receives all complaints and inquiries for the Department of Insurance, legislators and elected officials.
- Assesses, investigates, and resolves difficult issues to achieve member satisfaction.
- Performs other duties as required.
Qualifications:
JOB SPECIFICATIONS
- Bachelor’s degree or equivalent experience; RN licensure required.
- Previous (1-2 years) supervisory experience preferred.
- Experience in processing and working with all types of products including HMO, PPO, CCPPO and Indemnity under both fully insured and self-funded arrangements.
- Expert knowledge of medical terminology required.
- Previous (1-2 years) of direct customer service experience preferred.
- Ability to train employees on all products, procedures, and systems.
Coventry Health Care is an Affirmative Action/Equal Opportunity Employer, and we are committed to building a talented and diverse team.
Job: Professionals
Primary Location: Harrisburg, PA, US
Organization: 23000 - HealthAmerica Pennsylvania Inc
Schedule: Full-time
Job Posting: 2013-01-29 00:00:00.0
Job ID: 1310344