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Appeal and Grievances Specialist

Eingestellt von Synectics

Gesuchte Skills: Cms

Projektbeschreibung

The Appeal and Grievances Specialist (A&G Specialist) will receive, investigate and resolve member and provider complains and appeals exercising strong independent judgment. This position will provide resolution of complaints in compliance with CMS, DHCS, DMHC, MBMIB and NCQA regulatory requirements. The A benefit coverage appeals and reconsiderations, and complex provider claims disputes. The position is further responsible for tracking, trending and reporting complaints and appeals, as well as participating in internal and external oversight activities.

Responsible for maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting noncompliance, adhering to company policy and procedures, including accreditation requirements, applicable federal, state and local laws and regulations.

SKILLS:

EDUCATION

- REQUIRED: High school diploma required.
- PREFERRED: Bachelors Degree or equivalent work experience.

EXPERIENCE

Required

- Requires strong knowledge of regulatory standards and claims processing; strong analytical, oral, written and presentation skills, able to monitor and be compliant with strict regulatory deadlines.
- 2 to 3 years experience in Managed Care with specific experience in resolving member and provider complaints and appeals issues, including eligibility, access to care, claims, benefit, and quality of care concerns.
- Experience working with firm deadlines, able to interpret and apply regulations.
- Must be organized, detail oriented, able to exercise strong independent judgment; poses conflict resolution and persuasion skills.
- A team player with excellent communication and presentation skills, able to work effectively with various internal departments/service areas, plan partners, participating provider groups and other external agencies.
- Proficient in MS Office applications, Word, Excel and Powerpoint.

PREFERRED

- 5-10 years experience in Managed Care working with Medicare, Medi-Cal and other State Sponsored programs.
- Knowledge of Medical terminology and strong advocacy experience.
- Proficient in MS Office applications, Access, Visio.

Projektdetails

  • Einsatzort:

    Los Angeles (Downtown), Vereinigte Staaten

  • Projektbeginn:

    asap

  • Projektdauer:

    Keine Angabe

  • Vertragsart:

    Contract

  • Berufserfahrung:

    Keine Angabe

Geforderte Qualifikationen

  • Kategorie:

    Webentwicklung

  • Skills:

    cms

Synectics