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 Representative Iis responsible for reviewing, analyzing and processing claims in accordance with policies and claims events to determine the extent of the company's liability and entitlement.
How you will make an impact:
Conducts investigation and review of customer grievances and appeals involving provision of service and benefit coverage issues.
Contacts customers to gather information and communicate disposition of case; documents interactions.
Generates written correspondence to customers such as members, providers and regulatory agencies.
Performs research to respond to inquiries and interprets policy provisions to determine the extent of company's liability and/or provider's/beneficiaries entitlement.
Responds to appeals from CS Units, Provider Inquiry Units, members, providers and/or others for resolution or affirmation of previously processed claims.
Ensures appropriate resolution to inquiries, grievances and appeals within specified timeframes established by either regulatory/accreditation agencies or customer needs.
Identifies barriers to customer satisfaction and recommends actions to address operational challenges.
Minimum Requirements
HS diploma or equivalent and a minimum of 1 year experience in health insurance business including customer service experience; or any combination of education and experience which would provide an equivalent background.
Preferred Skills, Capabilities and Experiences
Good verbal and written communication, organizational, interpersonal skills and PC proficiency strongly preferred.
