Location: New York, NY
Openings: 4 positions
Grievance/Appeals Representative II:
Reviews, analyzes and processes policies related to claims events to determine the extent of the company's liability and entitlement.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.Researches administrative or non-clinical aspects of the appeal, e.g. eligibility, benefit levels, overall adherence to policies and practices.May make decision on administrative appeals where guidelines are well documented and involve limited discretion.Prepares files for internal or external review by analysts, medical staff or outside consultant.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.Ensures appropriate resolution to inquiries, grievances and appeals within specified timeframes established by either regulatory/accreditation agencies or customer needs.Under minimal supervision resolves inquiries, grievances and appeals requests from 3+ customer types (i.e. member, provider and regulatory) and multiple products (i.e. HMO, POS, and PPO) related to non-clinical services and quality of service issues.Handles non-routine customer issues requiring adaptation of response or extensive research.Exercises judgment within set guidelines. Identifies barriers to customer satisfaction and recommends actions to address operational challenges.Demonstrated knowledge of regulatory and accreditation requirements, understanding of appeals process and utilization management, and systems software used in processing appeals.
Qualifications
Claims knowledge is helpful.Good oral and written communication skills.Ability to organize work, set and manage multiple priorities in a time sensitive manner.Basic word processing, data base management, and spreadsheet skills required. PC proficiency.HS diploma or equivalent; some college desired, or equivalent combination of education and experience.2-4 years related experience to include customer service in a managed care environment, medical office or health insurance required.Behavioral Health experience required.Experience in the Medical field or health insurance required.Customer service experience required.
Openings: 4 positions
Grievance/Appeals Representative II:
Reviews, analyzes and processes policies related to claims events to determine the extent of the company's liability and entitlement.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.Researches administrative or non-clinical aspects of the appeal, e.g. eligibility, benefit levels, overall adherence to policies and practices.May make decision on administrative appeals where guidelines are well documented and involve limited discretion.Prepares files for internal or external review by analysts, medical staff or outside consultant.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.Ensures appropriate resolution to inquiries, grievances and appeals within specified timeframes established by either regulatory/accreditation agencies or customer needs.Under minimal supervision resolves inquiries, grievances and appeals requests from 3+ customer types (i.e. member, provider and regulatory) and multiple products (i.e. HMO, POS, and PPO) related to non-clinical services and quality of service issues.Handles non-routine customer issues requiring adaptation of response or extensive research.Exercises judgment within set guidelines. Identifies barriers to customer satisfaction and recommends actions to address operational challenges.Demonstrated knowledge of regulatory and accreditation requirements, understanding of appeals process and utilization management, and systems software used in processing appeals.
Qualifications
Claims knowledge is helpful.Good oral and written communication skills.Ability to organize work, set and manage multiple priorities in a time sensitive manner.Basic word processing, data base management, and spreadsheet skills required. PC proficiency.HS diploma or equivalent; some college desired, or equivalent combination of education and experience.2-4 years related experience to include customer service in a managed care environment, medical office or health insurance required.Behavioral Health experience required.Experience in the Medical field or health insurance required.Customer service experience required.