Grievance/Appeals Representative
7 hours ago
Mindlance is a national recruiting company which partners with many of the leading employers across the country. Feel free to check us out at
Business Grievance/Appeals Representative
Location 1 WellPoint Way, Thousand Oaks CA 91362, USA
Division Healthcare
Contract 5 Months
QualificationsSUMMARY
· Reviews, analyzes and processes claims in accordance with policies and claims events to determine the extent of the company's liability and entitlement.
MAJOR JOB DUTIES AND RESPONSIBILITIES
· Conducts investigation and review of customer grievances and appeals involving provision of service and benefit coverage issues.
· Contacts customers to gather information and communicate disposition of case; documents interactions.
· Generates written correspondence to customers such as members, providers and regulatory agencies.
· Performs research to respond to inquiries and interprets policy provisions to determine the extent of company's liability and/or provider's/beneficiaries entitlement.
· Responds to appeals from CS Units, Provider Inquiry Units, members, providers and/or others for resolution or affirmation of previously processed claims.
· Ensures appropriate resolution to inquiries, grievances and appeals within specified timeframes established by either regulatory/accreditation agencies or customer needs.
· Triages clinical and non-clinical inquiries, grievances and appeals, prepares case files for member grievance committees/hearings.
· Summarizes and presents essential information for the clinical specialist or medical director and legal counsel.
· Responds to oral and written complaints sent to the Office of the Chairman, President or Vice President Complaints.
· Identifies barriers to customer satisfaction and recommends actions to address operational challenges.
· Thoroughly documents and logs inquiry/appeal/grievance information on Grievance and Appeal Tracking systems for accurate tracking and analysis.
· Good verbal and written communication, organizational and interpersonal skills.
· PC proficiency.
EDUCATION/EXPERIENCE
· High school diploma or equivalent required.
· 1 - 3 years health insurance business including customer service experience required.
· Fully proficient in all areas of claims and customer service; may need guidance and supervision to complete some functions.
If you are available and interested then please reply me with your "Chronological Resume" and call me on .
Additional InformationThanks & Regards,
Ranadheer Murari | Team Recruitment | Mindlance, Inc. | W:
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