Grievance and Appeals

NationsBenefits, LLC•Plantation, FL

11d

About The Position

As a member of The Grievance and Appeals Department, Specialists are responsible for investigating and processing grievances and appeals received by members or directly from contracted health plans. This is a challenging role with serious impact. You will need strong analytical skills and the ability to effectively interact with other departments. Specialists work collaboratively with other internal and external functional areas and stakeholders as necessary to resolve grievances and appeals in the allocated timeframes. You will also need to effectively draft correspondence that explains the grievance and appeals resolution/outcome as well as next steps/actions for the member and/or provider.

Requirements

College degree preferred
1-3 years of industry related experience in healthcare compliance, operations, customer service, quality, or applicable experience in healthcare
1-year grievance and appeals experience preferred.
Strong written and verbal communication skills and an ability to work with people from diverse backgrounds.
Medicare and Health Insurance knowledge
Ability to multi-task, good organizational, and time management skills.
Ability to act on feedback provided by showing ownership of their own development.
Ability to read, analyzes, and interprets verbal and written instructions.
Ability to write business correspondence.
Ability to effectively present information and respond to questions from members.
Ability to define problems collects data, establish facts, and draw valid conclusions.
Ability to work effectively within a team environment.
Strong interpersonal and written and verbal communication skills.
Clear, concise, and persuasive writing and presentation skills.
Ability to identity, analyze and investigate potential issues.

Nice To Haves

Grievance & Appeals, Customer Service, Training Quality assurance (3 years)

Responsibilities

Responds to member (customer) and client (health plan) inquiries (via phone, written, e-mail, or fax) regarding all aspects of our business in a professional, timely, accurate, and caring manner while consistently meeting all guidelines.
Reviews, research, and directs complaints, grievances to appropriate personnel, and follows up to ensure that resolution has occurred, documentation is complete, required time frames are met, and proper written communication of the decision has occurred. In most cases, prepares the written communication of the decision in plain written language for client.
Coordinates additional follow up activities with appropriate department managers and/or leads and tracks to conclusion.
Maintains grievance and appeal case files.
Responds to member, provider, client and other inquiries via telephone or written correspondence while meeting all corporate guidelines and client performance standards.
Responsible for coordination of all components of complaints/appeals including final communication to Client for final resolution and closure.
Follow up to assure complaint/appeal is handled within established timeframe to meet company and regulatory requirements.
Demonstrates appropriate customer-care skills such as empathy, active listening, courtesy, politeness, helpfulness, and other skills as identified.
Records, investigates, and resolves member complaints.
Assists in the education of new members/providers and in the re-education of existing members/providers regarding health plan procedures.
Track grievance case by client and line(s) of business for compliance and review.
Assist in resolving member and provider complaints.
Behaves in accordance with company core values and expectations (initiative, accountability)
Performs skills necessary to create a high-quality customer experience, as reflected through acceptable quality audit score and productivity.
Triage incomplete components of complaints to appropriate subject matter expert within company for resolution response content to be included in final resolution response.
Responsible for compliance with all federal, state, and local laws, rules and regulations affecting Company.