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Grievance and Appeals Resolution Specialist
1 month ago
About the Role
We are seeking a highly skilled Grievance & Appeals Specialist to join our team at EmblemHealth. As a key member of our organization, you will be responsible for responding to written and verbal grievances, complaints, and appeals submitted by members and providers in accordance with NCQA, CMS, State, and other regulations.
Key Responsibilities:
- Comprehensively review and evaluate appeal and grievance requests to identify and classify member and provider appeals, determining eligibility, benefits, and prior activity related to the claims, payment, or service in question.
- Provide written acknowledgment of member and provider correspondence, ensuring timely and accurate responses.
- Conduct thorough investigations of all member and provider correspondence, analyzing issues and obtaining responses and information from internal and external entities.
- Serve as liaison with EmblemHealth departments, delegated entities, medical groups, and network physicians to ensure timely resolution of cases.
- Research appeal files for completeness and accuracy, investigating deficiencies and consulting with internal areas as required.
- Accurately and completely prepare cases for medical and administrative review, detailing the findings of their investigation for consideration in the plan's determination.
- Monitor daily and weekly pending reports and personal worklists, ensuring internal and regulatory timeframes are met.
- Responsible for monitoring the effectuation of all resolution/outcomes resulting from internal appeals as well as all appeals reviewed through the IRE.
- Identify areas of potential improvement and provide feedback and recommendations to management on issue resolution, quality improvement, network contracting, policies, and procedures.
- Prepare written responses to all member and provider correspondence, addressing each complainant's issues and ensuring structurally accurate documentation.
- Ensure documentation requirements are met, creating and documenting service requests to track and resolve issues, and documenting final resolutions along with all required data.
Requirements:
- Associate Degree in a related field; Bachelor's preferred
- 3+ years of related professional work experience required
- Additional years of experience/training may be considered in lieu of educational requirements
- Excellent verbal and written communications skills required
- Ability to comprehend and produce grammatically accurate, error-free business correspondence required
- Proficiency in MS Office applications (especially word processing and database/spreadsheet) required
- Excellent problem-solving and analytical skills required
- Ability to work under pressure and deliver complete, accurate, and timely results required
- Excellent organization and time management skills required
- Customer service experience preferred
- Excellent product knowledge preferred
- Prior health industry and/or compliance work experience preferred
- Experience in a managed care/compliance environment preferred
