Medicare Advantage Appeals and Grievances Customer Experience Specialist

Blue Cross and Blue Shield of Kansas•Topeka, KS

3d•$28 - $33•Hybrid

About The Position

The MA Appeals and Grievances Specialist provides a world class customer service experience through processing and resolution of Medicare Advantage (MA) member, member representative, or provider appeals and grievances. May also process and resolve member, representative, provider, and other Blue Plan inquiries.

Requirements

High school diploma or equivalent required
Minimum 2 years' experience customer service required
Minimum 3 years' experience MA or Medicaid Appeals and Grievances required
Ability to interact positively with internal and external customers while demonstrating empathy, adaptability, and listening skills.
Ability to listen, talk type and perform research simultaneously using various research channels.
Ability to apply excellent reasoning, analytical, and problem-solving skills, and sound judgment.
Ability to conduct extensive research, provide analyses and solutions to unusual or recurring issues, at times using discretion.
Ability to efficiently manage dissimilar issues, determine priorities and meet regulatory and/or company deadlines.
Ability to demonstrate advanced human relations skills and communicate effectively both verbally and in writing.
Ability to maintain strict confidentiality in handling data related to job duties.
Ability to work collaboratively and cooperatively as a team member.
Ability to work within a self-initiated environment with little supervision.
Ability to achieve production-based performance goals.
Ability to effectively use computer programs and troubleshoot simple computer issues independently or with direction.
Ability to adhere to a rigid schedule and have regular and predictable attendance.
Ability to obtain and maintain any departmental or legally required certifications (e.g. CMS or BCBSA requirements).
Upon completion of training: Working knowledge of Blue Cross and Blue Shield of Kansas’ MA and other relevant systems and detailed knowledge of MA line of business and regulations governing MA appeals and grievances are required.

Nice To Haves

College or continuing education courses in communications and/or medical related fields preferred
Minimum 2 years' experience MA or other call center or production-based customer service experience preferred
Previous experience with Blue Plan preferred

Responsibilities

Process MA member, member representative or provider appeals, grievances, disputes or complaints to ensure all regulatory guidelines are met.
Interpret, analyze, and review all MA benefit offerings and their relevant language, corporate policies, administrative and operating procedures, information systems, and regulatory guidance to address a variety of issues which may not be clear or direct.
Manage time to optimize and prioritize work to ensure goals (internal, regulatory, etc.) are met in a fluctuating environment.
Use discretion to make judgment calls determining appropriate sources, directions, and parameters necessary to review and resolve issues in an extremely diverse, complex, and challenging business and regulatory environment. This can include interaction with a variety of internal and/or external contacts.
Develop effective working relationships with staff at every level within BCBSKS, other Plans, CMS Caseworkers or Account Manager, relevant suppliers and contractors, providers, and/or members and their representatives to facilitate accurate and timely resolution of cases.
Serve as a backup to the MA Customer Experience Representatives as business needs dictate. This involves researching, resolving, and responding to inquiries and correspondence via telephone, written and email communication. Inquiries may be regarding MA benefits, eligibility, coverage and plan changes, payments, claims, prior authorizations, appeals, and grievances.
Complete special projects related to appeals, grievances or other CXR responsibilities.