Appeals and Grievance Specialist

Presbyterian Healthcare Services

1d•$18 - $27•Onsite

About The Position

Presbyterian is hiring a skilled Appeals and Grievance Specialist to join our team. This is a full-time opportunity based at the Reverend Hugh Cooper Administrative Center. The role involves responding to verbal and written complaints, grievances, and requests for appeals that involve complex matters. The specialist will perform comprehensive research to clarify facts and circumstances, identify root causes, and ensure customers and health plan providers receive exceptional service. A key aspect of the role is making initial decisions regarding the resolution of complaints, grievances, or appeals based on completed research and ensuring issues are categorized for reporting to internal stakeholders, oversight committees, and regulatory agencies. The specialist will act as a member advocate, comparing grievant/appellant issues with the organization's documented facts.

Requirements

High School education or G.E.D. equivalent required.
Three years experience in a customer service setting required
One year in a health care environment is preferred.

Nice To Haves

Associates Degree preferred.
Experience in managed care field such as Claims or Member Services strongly preferred.
Experience with healthcare databases is preferred

Responsibilities

Perform research related to the facts and circumstances of a member and provider complaint, appeal, or grievance.
Gathers necessary documents (from internal and external resources) related to an appeal, grievance or complaint to develop a complete file.
Gathers information from clinical sources, medical records, chart reviews, admitting records, patient financial records, and from subject matter experts in order to research the facts of all complaints, grievances and appeals.
Uses available documentation including DART, provider manuals, member contracts and online policies and procedures to support accurate and consistent decisions relating to claims payment, authorizations, contractual issues, servicing and care standards, and all other operational aspects of the organization.
Document the substance of each complaint, grievance or appeal case according to legal requirements.
Make direct verbal contact with members and providers who have filed a complaint, grievance or appeal during research process in order to fully document the issue.
Communicate in writing with customers, members, providers or designated representative; using the regulatory compliant format on all issues both for acknowledgment and resolution.
Review all written correspondence for regulatory statutes and requirements for all customer types.
Professionally articulate orally and in writing an understanding of complex issues and detailed action plans.