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Appeals and Grievances Specialist
2 months ago
The Customer Solution Center Appeals and Grievances Specialist II will receive, investigate and resolve member and provider complaints and appeals exercising strong independent judgment.
This position will provide resolution of complaints in compliance with regulatory requirements, including CMS, DHCS, DMHC, MRMIB and NCQA standards.
This position reviews pre-service authorizations, concurrent and post-service medical necessity; benefit coverage appeals and reconsiderations, and complex provider claim disputes.
The position is further responsible for tracking, trending and reporting complaints and appeals, as well as participating in internal and external oversight activities.
The position is responsible for maintaining the privacy and confidentiality of information, protecting the assets of the organization, acting with ethics and integrity, reporting noncompliance, adhering to company policy and procedures, including accreditation requirements, applicable federal, state and local laws and regulations.
Duties- Identifies, investigates, and resolves administrative complaints, complex provider appeals and State Fair Hearing adhering to regulatory standards and regulations.
- Intakes, acknowledges, prepares case files and routes complaints to appropriate internal department for investigation and resolution, exercising strong independent judgment.
- Ensures integrity of A&G database by thorough, timely and accurate assignment of cases.
- Monitors closure of complaints and works with Quality Control Supervisor to resolve all database issues.
- Prepare and analyze monthly appeal and grievance reports to meet internal and external reporting requirements.
- Participates in internal and external oversight activities, inter-rater reliability reviews and focused audits.
- Recommends opportunities for improvement.
- Perform other duties as assigned.
- At least 2 years of experience in Managed Care with specific experience in resolving member and provider complaint and appeals issues, including eligibility, access to care, claims, benefit, and quality of care concerns.
- Experience working with firm deadlines, able to interpret and apply regulations.
- At least 5 years of experience in Managed Care working with Medicare, Medi-Cal and other State Sponsored programs.
- Knowledge of Medical terminology and strong advocacy experience.
- Proficient in MS Office applications, Access, Visio.
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