GENERAL PURPOSE:

The Appeals and Grievances Specialist will help ensure that the plan responds to complaints, grievances, and appeals in a timely, professional, and customer-focused manner, and is completed according to state and federal regulatory standards. The Appeals and Grievances Coordinator will ensure the accurate and timely working of the case files.

Primary Responsibilities:

• Must have a thorough understanding of Health Plan operations and business unit processes, workflows, and system requirements, including but not limited to, authorizations, billing, claims, regulatory compliance, and plan benefits.
• Ensures the timely and accurate documentation, review, routing, and tracking of member issues in compliance with regulations established by external regulating bodies and applicable state and federal laws.
• Handles multiple issues and prioritizes appropriately with the ability to organize work to meet deadlines.
• Conducts research by speaking with members and providers, reviewing members’ records and benefit plans, and obtaining responses from various business areas.
• Demonstrates ability to process complex information and deliver the information both verbally and written, in a professional, clear, concise, and articulate manner.
• Requires excellent interpersonal skills to communicate and work with multiple constituents and be able to recognize sensitive issues and when to escalate to Management.
• Prepares case files for Independent Review Entities that are well organized, contain relevant documentation, and are processed within the required timeframes.
• Maintains corporate policies and procedures and other formal documents pertinent to the complaint, grievance, and appeal function.

Education:

• Bachelor’s degree in Health Care Administration or related field, or at least 3-5 years processing Medicare Part C & Part D Grievances and Appeals from receipt to resolution.

Skills/Abilities:

• Strong communication (written/oral) and organization skills with great attention to detail. 
• Must be bilingual in English/Korean or English/Chinese
• Ability to interpret medical terminology, regulations/statutes and apply them without direct supervision.
• Exceptional presentation skills.
• Knowledge of Microsoft Office