Medicare Advantage Complaint Resolution Specialist
2 weeks ago
We are seeking a dedicated individual to take on the role of analyzing, investigating, and addressing complaints, appeals, and grievances from our clients and regulatory bodies.
Responsibilities include crafting detailed written responses to inquiries. Each correspondence must adhere to specific elements to comply with regulatory and accreditation standards.
This position operates in a high-pressure, high-volume environment that is subject to rigorous audits. We anticipate this role to be a long-term opportunity, with comprehensive training provided.
Ideal candidates will possess the following skills and attributes:
- Strong analytical abilities to assess situations, facts, and contextual information for informed decision-making or effective resolution implementation.
- Exceptional writing and proofreading capabilities.
- Outstanding verbal and written communication skills.
- Meticulous attention to detail and strong organizational skills.
- Capacity to thrive in a fast-paced setting with strict deadlines and high-quality expectations.
- Ability to perform well under pressure.
- Proficient in navigating various computer systems and databases.
- Prior customer service experience is essential.
Qualifications
• High School Diploma or GED is required; an Associate's degree is preferred.
• Minimum of two (2) years of customer service experience is required.
• Two (2) years of experience in health insurance and familiarity with state and federal regulations is preferred.
• Strong skills in analytical thinking, organization, time management, and problem-solving.
• Excellent verbal and written communication skills.
• Proficiency in PC applications (e.g., Microsoft Excel, Word, and Outlook).
• High regard for maintaining confidentiality of corporate information.
• Proven ability to build and maintain constructive relationships within internal and external teams to achieve departmental and corporate objectives.
• Ability to apply policies and procedures to reach accurate conclusions.
• Competence in analyzing, interpreting, and applying logic and reason, conducting research, and formulating clear and thorough responses.
• Quick adaptability to learn and navigate diverse products and information systems.
• Understanding of Medicare Advantage servicing structures related to grievances and appeals or experience in claims, with the ability to apply EOC research in case preparation is preferred.
• Demonstrated ability to manage multiple tasks/projects simultaneously with minimal supervision.
Medicare Advantage Responsibilities
1. Ensure compliance with CMS Chapter 13, CMS Audit Compliance, and Star Quality Measures.
2. Maintain accuracy in data entry.
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