Grievance and Appeals Resolution Specialist

2 weeks ago


Farmington, Connecticut, United States EmblemHealth Full time
About the Role

We are seeking a highly skilled Grievance and 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, appeals, and disputes submitted by members and providers.

Key Responsibilities
  • Appeals and Grievance Processing: Comprehensively review and evaluate appeal and grievance requests to identify and classify member and provider appeals. Determine eligibility, benefits, and prior activity related to the claims, payment, or service in question.
  • Correspondence and Communication: Provide written acknowledgment of member and provider correspondence. Make verbal contact with the member or authorized representative during the research process to further clarify, as needed, the member's complaint or appeal.
  • Investigation and Research: Conduct thorough investigations of all member and provider correspondence by analyzing all the issues involved and obtaining responses and information from internal and external entities.
  • Liaison and Collaboration: Serve as liaison with EmblemHealth departments, delegated entities, medical groups, and network physicians to ensure timely resolution of cases.
  • Case Preparation and Review: Accurately and completely prepare cases for medical and administrative review detailing the findings of their investigation for consideration in the plan's determination.
  • Monitoring and Reporting: Monitor daily and weekly pending reports and personal worklists, ensuring internal and regulatory timeframes are met.
  • Quality Improvement and Feedback: Identify areas of potential improvement and provide feedback and recommendations to management on issue resolution, quality improvement, network contracting, policies and procedures, administrative costs, cost-saving opportunities, best practices, and performance issues.
  • Documentation and Reporting: Ensure documentation requirements are met: create and document service requests to track and resolve issues; document final resolutions along with all required data to facilitate accurate reporting, tracking, and trending.
Requirements
  • Education: Associate Degree in a related field; Bachelor's preferred
  • Experience: 3+ years of related professional work experience required
  • Skills: 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.


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