Grievance & Appeals Representative
$40,000–$52,300 year
RemoteUnited States
Job Summary
Conduct comprehensive analytic reviews of clinical documentation to determine if grievances, appeals, or further requests are warranted. Investigate and resolve member and practitioner concerns by applying departmental policies and procedures while exercising judgment to prioritize work. Document interactions, maintain accurate records, and research issues to gather information supporting case resolution. Explain processes, policies, and resolution outcomes to members and providers. Collaborate with internal teams to resolve complex issues and escalate concerns requiring additional review. Manage tasks to meet service expectations and support quality, compliance, and member experience goals.
Required Qualifications
- Previous customer service experience
- Previous experience in the healthcare industry or medical field
- Must have experience in a production driven environment
- Intermediate experience with Microsoft Word and Excel
- Ability to work an 8-hour shift Monday – Friday between the hours of 8am-8pm with flexibility to work overtime based on business needs
- Must be passionate about contributing to an organization focused on continuously improving consumer experiences
Desired Qualifications
- Associate's or Bachelor's Degree
- Previous experience in medical claims processing
- Previous inbound call center or related customer service experience
- 1 - 3 years of grievance and appeals experience
- Medical terminology experience
- Bilingual (English and Spanish); with the ability to read, write, and speak English and Spanish
- Prior experience with Medicare
- Experience with the Claims Administration System (CAS)
- Knowledge of medical terminology
- Ability to manage large volume of documents including tracking, copying, faxing and scanning
- Excellent interpersonal skills with ability to sensitively and compassionately interact with geriatric population
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