Case Specialist - GAU

Blue Cross & Blue Shield of Rhode Island•Providence, RI

9d•Hybrid

About The Position

The GAU Case Specialist is responsible for investigating, managing, and resolving member and provider grievances, complaints, and appeals in accordance with organizational policies, regulatory requirements, and service-level agreements. This position performs detailed research, analyzes information from multiple sources, documents findings, prepares written determinations, and ensures all cases are processed accurately, timely, and in compliance with CMS, NCQA, state, and internal requirements.

Requirements

Strong analytical and critical-thinking skills.
Excellent written and verbal communication skills.
Ability to interpret regulatory requirements, policies, and benefit plans.
Strong organizational and time-management skills.
Ability to manage multiple priorities in a deadline-driven environment.
Attention to detail with a focus on accuracy and compliance.
Proficiency using Microsoft Office applications and case management systems.
Ability to work independently and collaboratively within a team environment.
Two or more years of relevant experience either administrative or with the company in another department with relevant knowledge.

Nice To Haves

Experience in healthcare operations, claims, customer service, grievances, appeals, complaints, utilization management, or related healthcare functions preferred.
Knowledge of Medicare, Commercial Health Insurance, CMS, NCQA, and regulatory requirements preferred.

Responsibilities

Manage a caseload of grievances, complaints, and appeals from receipt through final resolution.
Review and analyze case documentation, claims information, benefit plans, policies, contracts, and supporting records.
Conduct thorough investigations to determine the appropriate outcome for each case.
Document all case activity, research, and determinations in designated systems.
Ensure compliance with all regulatory and internal timeliness requirements.
Monitor assigned inventory and proactively communicate potential barriers to timely completion.
Research member, provider, and claim issues utilizing multiple systems and data sources.
Collaborate with internal departments, clinical staff, business partners, and external vendors as needed to obtain information required for case resolution.
Analyze contract language, medical policies, benefit plans, and regulatory guidance to support case determinations.
Identify trends, process gaps, and opportunities for operational improvements.
Maintain complete, accurate, and audit-ready case documentation.
Ensure all required fields, regulatory categories, and reporting elements are accurately completed.
Adhere to CMS, NCQA, HIPAA, state regulatory, and organizational requirements.
Support internal and external audit activities as requested.
Follow established departmental workflows, policies, and procedures.
Draft and generate acknowledgment and determination letters.
Communicate professionally with members, providers, delegates, and internal stakeholders.
Participate in meetings, huddles, training sessions, and calibration activities.
Provide clear and concise explanations regarding case findings and determinations when appropriate.
Meet established productivity, quality, and timeliness standards.
Maintain satisfactory quality review scores and documentation accuracy.
Demonstrate accountability for assigned work and performance goals.
Participate in continuous improvement initiatives and process enhancement efforts.
Assist with cross-training and departmental projects as assigned.