Location: This position will work a hybrid model (remote and office). Ideal candidates will live within 50 miles of one of our PulsePoint locations.
The Grievance & Appeals Coordinator is responsible for investigating and reviewing customer grievances and appeals regarding provision of service and benefit coverage issues. Triages clinical and non-clinical inquiries, grievances and appeals, prepares case files for member grievance committees/hearings.
How you will make an impact:
Summarizes and presents essential information for the clinical specialist or medical/dental director and legal counsel.
Responds to oral and written complaints sent to the Office of the Chairman, President or Vice President complaints.
Ensures appropriate resolution to inquiries, grievances and appeals within specified timeframes established by either regulatory/accreditation agencies or customer needs.
Contacts members to gather information and communicate disposition of case; documents interactions.
Generates written correspondence to members, providers and regulatory agencies.
Identifies barriers to customer satisfaction and recommends actions to address operational challenges.
Pursues ongoing education/training on benefits/services to ensure accurate resolution of grievances and appeals, and overall industry knowledge and development (i.e. HIAA, LOMA, etc.).
Operates a PC/image station to obtain and extract information; documents information, activities and changes in the database.
Minimum Requirements
Requires a HS Diploma or equivalent and 4 years progressively complex experience working in grievances and appeals; or any combination of education and experience which would provide an equivalent background.
