Appeals and Grievance Specialist II \ 29

TalentBurst•Irving, TX

2d•Onsite

About The Position

This position requires the ability to work independently researching and reviewing inquiries from members and providers. Also requires knowledge of benefit interpretation, claims reviews, CPT and ICD coding. Responsible for reviewing, classifying, researching and resolving member complaints (grievances and/or appeals) and communicating resolution to members or their authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid Services and TRICARE. Coordinates with pertinent departments to effectuate resolution resulting from grievance and appeals resolution decisions made at the plan level or by independent review entities. Adheres to Client Plan policies and procedures which are based on regulated state and federal policies pertaining to the processing of grievances and appeals. Analyzes grievance and appeals data and develops tracking and trending reports at prescribed frequencies for the explicit purpose of identifying and communicating trended root causes of member and provider dissatisfaction. Recommends process improvements to pertinent departments within the organization in order to achieve member and provider satisfaction and/or operational effectiveness and efficiencies which contribute to maximum Medicare STAR ratings.

Requirements

High school diploma
3 years customer service experience with Managed Care Plans
2 years appeal and grievance experience with Managed Care Plans
Knowledge of benefit interpretation
Knowledge of claims reviews
Knowledge of CPT and ICD coding

Responsibilities

Research and provide resolution to issues such as claim denials, member and provider complaints, and reconsideration and redetermination requests.
Integrate and analyze information from several sources.