Process appeals and grievances, analyze, research, and provide comprehensive responses in accordance with established regulatory and accreditation guidelines. Contact customers to gather information and communicate disposition of case. Conduct pertinent research in order to evaluate, respond to, and finalize case. Familiar with standard concepts, practices, and procedures for analyzing, interpreting data and applying contract and regulatory provisions.
Analyze, research, resolve and respond to confidential/sensitive complaints, appeals, grievances and organization determinations from members, member's representatives, providers, media outlets, senior leadership and regulatory agencies with established regulatory and accreditation guidelines.
Make appeals complaints and grievance decisions and communicate decision to the claimant within regulatory and accreditation guidelines for timeliness, adhering to the strictest of timeframes for urgent and non-urgent requests, as imposed by the various federal and state laws.
Provide comprehensive appeals and grievances responses that support the decision and comply with regulatory and accreditation guidelines, and support the appeal decision by referencing specific and applicable language from the plan documents, certificates, riders, and summary plan descriptions, or the internal rules, guidelines and protocols, as appropriate.
Analyze, research, resolve and respond to high level inquiries, referrals, complaints, and appeals received from various regulatory agencies and other sources.
Maintain thorough knowledge of internal policies, procedures, regulations, charters for accurate resolution of appeals, complaints and grievances, including existing laws and regulations and new ones.
Identify business problems and initiate corrective measures; direct servicing issues to appropriate areas for corrective action.
Develop/prepare reports regarding the types/volumes/causes of inquiries received.
Develop and enhance workflows and business processes to improve customer service, decrease operational costs, resolve business issues, and improve overall efficiency.
Remain up-to-date in the use of internal systems as well as vendor systems.
Perform other duties as requested.
"Qualifications"
High School Diploma or GED required. Bachelor's Degree in English, Communications or related field preferred.
Two (2) years customer service experience required.
Two (2) years health insurance experience and familiarity with health insurance state and federal regulations preferred.
Strong project management skills preferred.
Strong analytical, critical thinking, organizational, time management and problem resolution skills.
Excellent verbal and written communication skills.
Strong PC applications (i.e. Microsoft Excel, Word, and Outlook).
Knowledge of Blue Cross systems and operations preferred.
High regard for protecting confidentiality of corporate information.
Proven ability to foster and maintain open, collaborative and constructive relationships within internal, external and leadership to achieve departmental and corporate results.
Ability to apply policies and procedures to arrive at accurate conclusions.
Ability to analyze, interpret, apply reason and logic, conduct research structure a clear and thorough response.
Ability to quickly learn and navigate diverse products and information systems.
Other related skills and/or abilities may be required to perform this job.
BCN MAPPO Pharmacy (refer to above requirements)
Blue Care Network Customer Service/Special Inquiries
Represent Blue Care Network in writing and at formal hearings conducted by the Regulatory/Accrediting Agencies.
Working knowledge of ACD telephone system and call center, preferred.
Knowledge of imaging technology, preferred.
Knowledge of OFIS, NCQA and MTM guideline and requirements, preferred.
Extensive knowledge of HMO/Health insurance terminology, preferred
Executive Services
Coordinate, facilitate, and conduct managerial-level conferences with customers and their authorized representatives, adhering to the regulations.
Coordinate external reviews with regulating agencies and contracted entities.
Support OGC in preparing cases for litigation and appear in court as an expert witness, as requested/necessary.
Accountable for regulatory and accreditation compliance.
Full understanding of relationships with group's customers, as they relate to the handling/coordination of appeals.
Medicare Advantage
Accountable for CMS Chapter 13, CMS Audit Compliance and Star Quality Measures: a.Member rights, b.Timely decisions about appeals, c.Fairness of the health plan's appeal decisions based on an independent reviewer
Data entry accuracy is required.
Full understanding of Medicare Advantage servicing environment, internal servicing partners and overall service center structure to include call center/servicing/escalations.
All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, gender identity, protected veteran status or status as an individual with a disability.
