Member Appeals & Grievances Specialist I

Viva Health•Birmingham, AL

7d•Hybrid

About The Position

The Member Appeals & Grievances Specialist will analyze and resolve all Medicare appeals and grievances received from members, non-contracted providers and government entities. This role will coordinate a timely resolution according to state and federal guidelines and VIVA HEALTH policies and procedures. This position will participate in an on-call rotation to process appeals and grievances on weekends and holidays. VIVA HEALTH, part of the renowned University of Alabama at Birmingham (UAB) Health System, is a health maintenance organization providing quality, accessible health care. Our employees are a part of the communities they serve and proudly partner with members on their healthcare journeys. VIVA HEALTH has been recognized by Centers for Medicare & Medicaid Services (CMS) as a high-performing health plan and has been repeatedly ranked as one of the nation's Best Places to Work by Modern Healthcare.

Requirements

High School diploma or GED
1 – 3 years’ experience in managed care, health care customer service, or appeals and grievances
Excellent written and verbal communication skills, interpersonal skills, organization skills, and the ability to handle multiple tasks
Ability to carefully follow processes in sequential order
Ability to meet established productivity, schedule adherence, and quality standards
Knowledge of computer platforms and applications of Microsoft Office
Ability to use critical thinking skills to develop solutions to non-clinical issues using fact-based decision making
Ability to work occasional planned and unplanned overtime to meet deadlines with minimal supervision

Nice To Haves

Associates’ Degree
Experience working with the elderly population
1 – 3 years’ experience processing Medicare appeals and grievances
Knowledge of Medicare regulations
Experience with administrative and/or coordinator positions with exposure to PHI

Responsibilities

Process member and non-contracted provider Medicare Part C and Part D grievances and appeals according to federal and state regulations and internal, organizational policies and procedures.
Collaborate with internal and external subject matter experts to obtain benefit and/or clinical opinions/interpretations.
Identify training, process improvement, and other ways to maximize plan performance and customer satisfaction.
Act as subject matter expert regarding grievances and appeals.
Prepare for and participate in all required audits.
Participate in on-call rotation on weekends and holidays.