Responsible for handling the review process for grievances, appeals, or denials including investigating, preparing and presenting appropriate materials for review. Resolves member concerns in partnership with internal and external departments while ensuring compliance with regulatory rules and timeframes within mandated timeframes and compliance.
Essential Functions:
- Participates in handling the grievances, appeals/denials process.
- Ensures appeals are processed in accordance with regulations, compliance standards and policies and procedures.
- Meets timeframes for performance while balancing the need to produce high quality work related to complex and sensitive member issues.
- Investigates all issues, including collection of appropriate data, preparation and presentation of documents to decision makers.
- Informs members or their authorized representatives, physicians and other stakeholders of Health Plan's determinations.
- Collaborates with internal staff, other MS Departments, managers and physicians to seek resolution on issues and cases affecting member while ensuring compliance, documentation and enhancing members' experience.
- Ensures integrity of departmental database by thorough, timely and accurate entry.
- Mentors others in preparation for positions of increased responsibility.
- Participates in departmental meetings, trainings and audits as requested.
- Answer questions and manages members on existing/open cases.
Qualifications:
Basic Qualifications:
- Bachelors' degree or a minimum of four (4) years equivalent experience in a complex HMO or customer service setting.
- Excellent interpersonal, verbal and written communication skills.
- Demonstrated ability to compose high quality, detailed written communication.
- Ability to identify issues, gather and assess information.
- Ability to prioritize work and ensure all compliance elements are met.
- Demonstrated conflict resolution and mediation skills with ability to secure action from multiple stakeholders.
- Ability to use sound judgment and to handle complex issues independently, but with the knowledge and ability to escalate and ask for help when needed.
- Ability to multitask and manage time in order to perform well on long term projects while being flexible enough to assimilate short term projects on an ongoing basis.
- Ability to work with peers in self managed teams.
- Knowledge of member grievance and appeals processing preferred.
- Must be able to work in a Labor/Management Partnership environment.
External hires must pass a background check/drug screen.
We are proud to be an equal opportunity/affirmative action employer.