Healthcare Greivance and Appeals Rep - 6 Month Contract

HEALTHCARE GRIEVANCE AND APPEALS REPRESENTATIVE

DESCRIPTION:

POSITION LOCATED WITHIN THE CORRESPONDENCE CENTER, REPORTING TO THE CORRESPONDENCE CENTER TEAM LEAD OR CORRESPONDENCE CENTER ASSISTANT DIRECTOR.

RESPONSIBLE FOR HANDLING GRIEVANCES AND APPEALS REVIEW PROCESS THROUGH INVESTIGATION, PREPARATION, EFFECTUATION, AND PRESENTATION OF APPROPRIATE MATERIALS FOR REVIEW.

PARTNER WITH INTERNAL AND EXTERNAL DEPARTMENTS, MEDICAL GROUP AND STAFF TO ACHIEVE RESOLUTION FOR MEMBER CONCERNS.

MANAGES DATABASE FOR CASES.

RESPONSIBLE FOR TIMELY CASE RESOLUTION AND COMPLIANCE WITH FEDERAL AND STATE REGULATIONS, LAWS AND ACCREDITATION STANDARDS.

ACCOUNTABLE FOR INVESTIGATION OF ALL ISSUES, INCLUDING COLLECTION AND DOCUMENTATION OF APPROPRIATE DATA.

IDENTIFY AND ADDRESS SPECIALTY/FLAGGED CASES AND FOLLOW APPROPRIATE PROCESSES FOR DIFFERENT TYPES OF CASES

COMMUNICATE WITH A DIVERSE SET OF INTERNAL AND EXTERNAL CLIENTELE TO ACHIEVE EXCELLENT RESULTS IN THE AREAS OF COMPLAINT AND GRIEVANCE HANDLING, COMPLIANCE, DOCUMENTATION AND ENHANCEMENT OF THE MEMBER EXPERIENCE.

RESEARCH, RESOLVE AND COMMUNICATE COMPLAINTS AND GRIEVANCES FILED BY MEMBERS AND COMMUNICATE HEALTH PLAN'S DECISIONS APPROPRIATELY BACK TO MEMBER OR THEIR AUTHORIZED REPRESENTATIVES

ENSURE THAT COMPLAINTS AND GRIEVANCES ARE PROCESSED IN ACCORDANCE WITH REGULATIONS, COMPLIANCE STANDARDS AND POLICIES AND PROCEDURES.

MEET TIMEFRAMES FOR PERFORMANCE WHILE BALANCING THE NEED TO PRODUCE HIGH QUALITY WORK RELATED TO COMPLEX AND SENSITIVE MEMBER ISSUES.

ENSURE INTEGRITY OF DEPARTMENTAL DATABASE BY THOROUGH, TIMELY AND ACCURATE ENTRY, CONSISTENT WITH REGULATORY PROTOCOLS AND EFFECTIVELY MANAGE CASE RESOLUTION INBOX EVERYDAY PARTICIPATE IN DEPARTMENTAL MEETINGS, TRAININGS AND AUDITS AS REQUESTED.

ANSWER QUESTIONS AND MANAGE MEMBERS ON EXISTING/OPEN CASES

ESCALATE ISSUES TO MANAGEMENT AS APPROPRIATE TO MAINTAIN COMPLIANCE.

REQUIREMENTS:

3+ YEARS EXPERIENCE IN A SERVICE RELATED INDUSTRY, CALL CENTER EXPERIENCE PREFERRED.

TWO YEARS EXPERIENCE IN A COMPLEX HEALTH CARE ENVIRONMENT

LETTER WRITING BACKGROUND (IE. ENGLISH DEGREE, LITERATURE DEGREES, PUBLICATION WORK HISTORY, ETC) -CUSTOMER SERVICE BACKGROUND (WORK EXPERIENCE IN A FACE TO FACE ENVIRONMENT OR HIGH CUSTOMER INTERACTION)

ANALYTICAL/CRITICAL THINKING - THIS JOB IS WORKING MEMBER PROBLEMS IN A MULTI-FACETED ORGANIZATION. -NEEDS TO IDENTIFY ROOT CAUSE, DECISION MAKER AND CAN EXPLAIN TO MEMBERS/STAKEHOLDERS

REGULATORY KNOWLEDGE (DMHC, CMS, DHCS, JOC, NCQA, ETC) THIS JOB WOULD BE CLOSE TO DMHC REGULATIONS

SELF-DRIVEN, CAN MANAGE SHIFTING PRIORITIES AND HAS A TEAM ATTITUDE

STRONG WRITING SKILLS, SYNTAX, GRAMMAR AND SPELLING COMPETENCY.

STRONG CUSTOMER SERVICE, PHONE SKILLS IN DIFFUSING MEMBER COMPLAINTS

MANAGER WOULD LIKE THEM TO UNDERSTAND CUSTOMER SERVICE DYNAMICS BUT HAVE ALSO PROVEN WRITING SKILLS (ENGLISH OR COMMUNICATIONS DEGREE, CORRESPONDENCE EXPERIENCE ETC.)

EXCELLENT INTERPERSONAL, VERBAL AND WRITTEN COMMUNICATION SKILLS.

ABILITY TO WORK WITH PEERS IN SELF-MANAGED TEAMS.

ABILITY TO PRIORITIZE WORK AND ENSURE ALL COMPLIANCE ELEMENTS ARE MET.

DEMONSTRATED CONFLICT RESOLUTION AND MEDIATION SKILLS WITH ABILITY TO SECURE ACTION FROM MULTIPLE STAKEHOLDERS.

ABILITY TO USE SOUND JUDGMENT AND TO HANDLE COMPLEX ISSUES INDEPENDENTLY, BUT WITH THE KNOWLEDGE AND ABILITY TO ESCALATE AND ASK FOR HELP WHEN NEEDED.

DEMONSTRATED ABILITY TO WORK IN A TIME-SENSITIVE ENVIRONMENT INVOLVING PATIENTS, FAMILY MEMBERS AND ADVOCATES.

EXTENSIVE WORKING KNOWLEDGE OF PERSONAL COMPUTERS TO INCLUDE WINDOWS BASED SOFTWARE APPLICATIONS, MS WORD, ETC.

ABILITY TO MULTITASK AND MANAGE TIME IN ORDER TO PERFORM WELL ON LONG TERM PROJECTS WHILE BEING FLEXIBLE ENOUGH TO ASSIMILATE SHORT TERM PROJECTS ON AN ONGOING BASIS.

MUST BE ABLE TO WORK IN A LABOR/MANAGEMENT PARTNERSHIP ENVIRONMENT.

STRONG WORKING KNOWLEDGE OF FEDERAL AND STATE REGULATIONS, LAWS AND ACCREDITATION STANDARDS RELATED TO HEALTH CARE AND MANAGED CARE ORGANIZATIONS.

KNOWLEDGE OF MEMBER COMPLAINT AND GRIEVANCE PROCESSING

COMPETENT WORKING KNOWLEDGE OF HEALTH PLAN BENEFITS PLAN/CONTRACTS/SYSTEMS STRONGLY PREFERRED.

EDUCATIONAL REQUIREMENT - HIGH SCHOOL DIPLOMA OR GED REQUIRED. SOME COLLEGE PREFERRED.