Grievance/Appeals Representative 1

Job Description

This is an entry level position in the Enterprise Grievance & Appeals Department that reviews, analyzes and processes non-complex pre service and post service grievances and appeals requests from customer types (i.e. member, provider, regulatory and third party) and multiple products (i.e. HMO, POS, PPO, EPO, CDHP, and indemnity) related to clinical and non-clinical services, quality of service, and quality of care issues to include executive and regulatory grievances.

MAJOR JOB DUTIES AND RESPONSIBILITIES: Reviews, analyzes and processes non-complex grievances and appeals in accordance with external accreditation and regulatory requirements, internal policies and claims events requiring adaptation of written response in clear, understandable language. Utilizes guidelines and review tools to conduct extensive research and analyze the grievance and appeal issue(s) and pertinent claims and medical records to either approve or summarize and route to nursing and/or medical staff for review. The grievance and appeal work is subject to applicable accreditation and regulatory standards and requirements. As such, the analyst will strictly follow department guidelines and tools to conduct their reviews. The file review components of the URAC and NCQA accreditations are must pass items to achieve the accreditation. Analyzes and renders determinations on assigned non-complex grievance and appeal issues and completion of the respective written communication documents to convey the determination. Responsibilities exclude conducting any utilization or medical management review activities which require the interpretation of clinical information. The analyst may serve as a liaison between grievances & appeals and /or medical management, legal, and/or service operations and other internal departments.

Qualifications

EDUCATION/EXPERIENCE: Requires a High school diploma or GED; 3 to 5 years’ experience working in grievances and appeals, claims, or customer service, or any combination of education and/or experience which would provide an equivalent background. SKILLS: Familiarity with medical coding and medical terminology, demonstrated business writing proficiency, understanding of provider networks, the medical management process, claims process, WellPoint internal business processes, and internal local technology.

Additional Information

Looking for candidates who have 3 to 5 years experience working in grievances and appeals, claims, or customer service, or any combination of education and/or experience which would provide an equivalent background. If you are interested feel free to reach Priti Kumari at 732-847-2541 or send me the updated resume on pritik@mindlance(dot)com