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Healthcare Grievance and Appeals Specialist - Min 3 Month Contract

Eingestellt von Enclipse Corp.

Projektbeschreibung

HEALTHCARE GRIEVANCE AND APPEALS SPECIALIST

DESCRIPTION:

RESPONSIBLE FOR HANDLING THE REVIEW PROCESS FOR APPEALS OR DENIALS INCLUDING INVESTIGATING, PREPARING AND PRESENTING APPROPRIATE MATERIALS FOR REVIEW.

RESOLVES MEMBER CONCERNS IN PARTNERSHIP WITH INTERNAL AND EXTERNAL DEPARTMENTS WHILE ENSURING COMPLIANCE WITH REGULATORY RULES AND TIMEFRAMES WITHIN MANDATED TIMEFRAMES AND COMPLIANCE.

ESSENTIAL FUNCTIONS:

PARTICIPATES IN HANDLING THE APPEALS/DENIALS PROCESS.

ENSURES APPEALS ARE PROCESSED IN ACCORDANCE WITH REGULATIONS, COMPLIANCE STANDARDS AND POLICIES AND PROCEDURES.

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

INVESTIGATES ALL ISSUES, INCLUDING COLLECTION OF APPROPRIATE DATA, PREPARATION AND PRESENTATION OF DOCUMENTS TO DECISION MAKERS.

INFORMS MEMBERS OR THEIR AUTHORIZED REPRESENTATIVES, PHYSICIANS AND OTHER STAKEHOLDERS OF HEALTH PLAN'S DETERMINATIONS.

COLLABORATES WITH INTERNAL STAFF, OTHER UM DEPARTMENTS, MANAGERS AND PHYSICIANS TO SEEK RESOLUTION ON ISSUES AND CASES AFFECTING MEMBER WHILE ENSURING COMPLIANCE, DOCUMENTATION AND ENHANCING MEMBERS' EXPERIENCE.

ENSURES INTEGRITY OF DEPARTMENTAL DATABASE BY THOROUGH, TIMELY AND ACCURATE ENTRY.

MENTORS OTHERS IN PREPARATION FOR POSITIONS OF INCREASED RESPONSIBILITY.

PARTICIPATES IN DEPARTMENTAL MEETINGS, TRAININGS AND AUDITS AS REQUESTED.

ANSWER QUESTIONS AND MANAGES EXISTING/OPEN CASES.

REQUIREMENTS:

BACHELORS' DEGREE (STRONGLY PREFERRED, HS/GED REQUIRED) OR A MINIMUM OF FOUR (4) YEARS EQUIVALENT EXPERIENCE IN A COMPLEX HMO OR CUSTOMER SERVICE SETTING.

EXCELLENT INTERPERSONAL, VERBAL AND WRITTEN COMMUNICATION SKILLS.

DEMONSTRATED ABILITY TO COMPOSE HIGH QUALITY, DETAILED WRITTEN COMMUNICATION.

ABILITY TO IDENTIFY ISSUES, GATHER AND ASSESS INFORMATION.

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

ABILITY TO WORK WITH PEERS IN SELF-MANAGED TEAMS.

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 PREFERRED.

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

Projektdetails

  • Vertragsart:

    Contract

  • Berufserfahrung:

    Keine Angabe

Geforderte Qualifikationen

  • Kategorie:

    Sonstiges

Enclipse Corp.