Member Services Grievance Resolution Specialist
4 days ago
The Member Services Grievance Coordinator is responsible for managing the resolution of member and provider complaints and grievances related to quality of care, access to care, and benefit determinations.
Key Responsibilities- Manage complaints and grievances through research, documentation, and escalation to the Medical Director as necessary.
- Collaborate with internal teams, including Member Services, Claims, and Legal, to resolve complex issues.
- Log, track, and process complaints and grievances using the electronic database, ensuring documentation complies with regulatory and client requirements.
- Prepare reports on key performance indicators (KPIs) for internal use and client reporting.
- Coordinate Complaint Subcommittee meetings by preparing agendas, notifying participants, and maintaining meeting minutes.
- Compose final decision letters to members and providers, reflecting the Complaint Subcommittee's decisions.
- Ensure decisions are implemented, and assist unsatisfied members with proper next steps.
- Serve as a point of contact for escalated calls, providing professional and courteous support.
- A High School Diploma/GED is required. An Associate's degree is preferred but not required.
- Candidates should have 2-3 years of experience in customer service, complaint resolution, or similar roles. Experience in the healthcare or vision insurance field is a plus.
- Customer Service/Escalation Experience: Proven experience handling customer service escalations.
- Strong Written Communication Skills: Ability to draft clear, professional correspondence with a focus on member and provider interactions.
- Grievance and Appeals Experience: Direct experience managing grievances and appeals processes.
- Medicaid/Medicare Experience: Familiarity with handling member correspondence under Medicaid and Medicare.
- Managed Vision Care/Insurance Experience: Experience in the vision care or insurance industries.
- Meet established quality and productivity standards, including compliance with client performance guarantees and applicable federal/state regulations.
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