Job description

ESSENTIAL DUTIES AND RESPONSIBILITIES

1. Coordinating the intake of appeal and grievances requests from members and providers into the designated systems.

2. Generating Acknowledgement Letters to mail to appellants and answering general appeal status questions.

3. Compiling case files to be sent to Independent Review Entity (IRE).

4. Ensuring adherence with state and federal regulatory timeframes for handling cases including acknowledging cases, resolving cases, monitoring effectuation of resolution, completing resolution letters and communicating with members and providers within required timeframes.

5. Preparing case files for Independent Review Entities or other escalated types of cases, including documentation of the Statement of Position and case narratives.

6. Developing Grievance and Appeal request information from designated databases.

7. Assisting Investigation and Appeals Specialists with appeal and grievance resolutions. 8. Develops and maintains positive customer relations and coordinates with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner

9. Wears a complete uniform or professional business attire (dependent on job duty) and keeps a clean and neat appearance during working hours.

10. Demonstrates courtesy and politeness to patients, visitors, callers and other employees.

11. Maintains open channels of communication with center administration and other company departments; Answers all inquiries in a professional and courteous manner. 12. Participates in training and in-service education as required.

13. Participates in department, clinic and other meetings as requested.

14. Complies with the organization's policies and procedures and maintains confidentiality in accordance with state and federal laws.

15. Participates in special projects and performs other duties as assigned.

QUALIFICATIONS

• Two (2) years experience working in a managed care environment in grievance or appeals, claims or related experience. Or Equivalent Combination of Training and Experience

• Exceptional problem solving skills.

• Must be able to effectively communicate verbally.

• Computer Skills: Proficient in Microsoft Office Applications. Familiarity with medical terminology, health plan documents, or benefit plan design

• Experience working with vulnerable populations

• Demonstrated ability to quickly build rapport and respond to customers in a compassionate manner by identifying and exceeding customer expectations (responding in respectful, timely manner, consistently meeting commitments)

Job Type: Full-time

Pay: $18.00 - $25.00 per hour

Benefits:

• 401(k)
• 401(k) matching
• Health insurance
• Paid time off

Medical specialties:

• Geriatrics

Schedule:

• 8 hour shift
• Monday to Friday
• Overtime

Experience:

• Medicare: 1 year (Required)

Language:

• BOTH English and Spanish FLUENTLY (Required)

Work Location: In person

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