Appeals and Grievances Representative, Intermediate

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