Specialist, Admin Complaints, Grievances & Appeals
About The Position
You will be responsible for the comprehensive management and resolution of complex administrative member and/or provider grievances and appeals. You will serve as a subject matter expert on non-clinical case resolution, focusing on sensitive member issues such as claims concerns, access barriers, benefits concerns and complex service inquiries. You will drive the resolution process to meet regulatory standards set by the health plan's governing bodies, while championing member satisfaction and retention. You will report into the Associate Director, Member & Provider Escalations.
Requirements
- 1+ years of professional experience in a regulated industry, such as healthcare, insurance
- 1+ years of experience independently managing a demanding caseload with multi-step workflows, from initial intake through investigation, resolution, and final documentation, while meeting competing priorities.
- 1+ years of experience with directly managing escalated customer, member or provider cases
- 1+ years of experience with drafting and issuing formal written communication to member or providers
- 1+ years of experience working in a highly structured, workflow driven, environment
Nice To Haves
- Bilingual in Spanish (reading and writing)
- Bachelor's degree
- Experience in health care administration.
- Involvement in departmental or cross-functional process improvement or quality initiatives.
Responsibilities
- Follow established workflows to acknowledge, log, and perform initial triage on complex or escalated administrative grievances from members and/or providers
- Conduct thorough, multi-faceted investigations by gathering and analyzing internal data, call logs, correspondence, etc.
- Use workflows to reconstruct complex event timelines involving prior authorizations, claims processing, and system-based adjudication edits to accurately determine the root cause of member and/or provider issues.
- Liaise with internal departments, such as Member Services, Eligibility & Benefits, and Claims, to obtain necessary information for complete case resolution.
- Based on investigative findings, determine a resolution strategy that is both fair and compliant with company and regulatory guidelines, utilizing established workflows.
- Escalate the issue to leadership for further guidance on resolution strategy, as needed
- Draft clear, accurate, complete resolution letters, ensuring all required regulatory elements are included
- Maintain meticulous and comprehensive case files in the case management system to ensure a clear and complete audit trail for each case
- Monitor and manage case timelines to ensure strict adherence to all federal and state mandated deadlines
- Compliance with all applicable laws and regulations
- Other duties as assigned
Benefits
- medical, dental, and vision benefits
- 11 paid holidays
- paid sick time
- paid parental leave
- 401(k) plan participation
- life and disability insurance
- paid wellness time and reimbursements
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
Number of Employees
1,001-5,000 employees
