Job Description

Your Role

The Clinical Appeals and Grievances team researches and resolves member/subscriber grievances, appeals and complaints, and interprets and explains health plan benefits, policies, and procedures to appellant. The Appeals and Grievances Representative, Intermediate will report to the team’s Operational Supervisor. In this role you will clarify issues, educate members in the process and interpret/explain health plan benefits, policies, procedures and functions to members and providers. You will be responsible for producing complex written correspondence to resolve member grievances, appeals and complaints.

Our leadership model is about developing great leaders at all levels and creating opportunities for our people to grow – personally, professionally, and financially. We are looking for leaders that are energized by creative and critical thinking, building and sustaining high-performing teams, getting results the right way, and fostering continuous learning.

Your Work
In this role, you will:

• Assist with telephone inquiries regarding member appeals.
• Respond to member appeals, grievances, and complaints.
• Clarify and educate members on appeals and grievance policies.
• Interpret and explain health plan benefits, policies, procedures and functions to members and providers.
• Administer ongoing grievance tracking, trending, and reporting for assigned grievances.
• Effectively work with both internal and external business partners to obtain case specific documentation that may be required and prepare cases for medical review.
• Interpret and consistently perform at established Intermediate performance metrics including quality and production standards.
• Make independent decisions based on demonstrated skill proficiency and use available resources, documentation, and tools.
• Demonstrate flexibility, adaptability and support change in business needs that are made to improve team performance.
  

Your Knowledge and Experience

• Requires a high school diploma or GED
• Requires at least 2 years in health insurance operations such as I&M, Claims, Customer Services, Regulatory Affairs and/or Appeals/Grievances or similar combination

• Requires knowledge of Microsoft Systems such as Power Point, Excel, and Word

Hybrid Virtual Work
This role allows employees to work virtually full-time, however employees will be expected to come to the office based on business need.