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The Midtown Group
California, MO, United States
Claims Resolutions Specialist Job Description Salary Grade: - $25.87 - $38.00/hr Job Summary The Claims Resolution Specialist will be the first line of contact for health providers. The incumbent will assist providers with questions related to the payment of claims and resolution of claims payment issues. Position Information Department: Claim
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Job Source: LC EXCUSIVECalifornia, MO, United States
Department(s): Grievance & Appeals Resolution Services (GARS)
Reports to: Manager, Grievance & Appeals
Salary: $24.52 - $31.04
Duration : up to 6 months
Job Summary
The Grievance Resolution Specialist coordinates the Grievance and Appeal resolution process, responds to verbal and written Grievances and Appeals from members and/or providers relating to member eligibility and benefits, contract administration, claims processing, utilization management decisions, and pharmacy and vision decisions. The incumbent has frequent external contact with members and families, healthcare providers, health networks, third-party administrators, and regulators. The incumbent collaborates with internal departments such as Customer Service, Provider Operations, Pharmacy, and Medical Management to identify factors necessary for the optimal resolution of Grievances and Appeals.
Position Responsibilities
Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity, and accountability.
Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.
Maintains adequate information in systems; ensures data collection, summarization, integration, and reporting which includes case creation and management and events/activity tracking.
Gathers pertinent information regarding the grievances and appeals received, including, but not limited to, member or provider concerns, supporting information related to initial decision-making, new information supporting the grievance or appeal, or supplemental information required to evaluate grievances and appeals within regulatory requirements.
Coordinates and/or participates in case discussion with operational experts to result in a final case disposition as needed.
Evaluates case details, proposes recommendations, or makes decisions as applicable; ensures organization decision is implemented according to the Grievance and Appeals policies and case resolution.
Develops resolution letters and correspondence to members and providers.
Communicates with internal and external customers to ensure timely review and resolution of grievances or appeals.
Initiates referrals to Quality Improvement department as applicable and facilitates responses to members according to client policy.
Assists with Health Networks’ compliance process.
Identifies trends and root cause of issues; proposes solutions or escalates ongoing issues to management.
Meets performance measurement goals for Grievance and Appeals Resolution Services.
Completes other projects and duties as assigned.
Possesses The Ability To
Exercise discretion in processing confidential information.
Identify critical issues and make recommendations or decisions by using critical thinking skills.
Document and present case research findings and formulate resolution letters.
Communicate clearly and concisely both, orally and in writing.
Establish and maintain effective working relationships with leadership and staff.
Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position assignment.
Experience & Education
High School diploma or equivalent required.
1 year of experience in any of the following areas: Grievances and Appeals, Claims, Regulatory Compliance, Customer Service, or related fields required.
An equivalent combination of education and experience sufficient to successfully perform the essential duties of the position such as those listed above is also qualifying.
Preferred Qualifications
Associate degree in Business, Health Care Administration, or related field.
Experience in healthcare practice standards, for both government and commercial plans.
Bilingual in English and in one of the defined threshold languages (Arabic, Farsi, Chinese, Korean, Spanish, Vietnamese).
Knowledge Of
State and Federal regulations regarding the healthcare industry.
Managed Care industry, health care, Medical/Medicaid, and Medicare processes.
Appeals and Grievances operating procedures and processes strongly preferred.
The Midtown Group is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran. We are a small, woman-owned business certified by the Women’s Business Enterprise National Council (WBENC). Operating from our headquarters in Washington, DC, we provide trusted staffing services nationwide. Our clients include thousands of the most prestigious Fortune 500 companies, law firms, financial organizations, tech innovators, non-profits, and lobbying firms, as well as federal, state and local government agencies.
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Email Alert for Grievance Resolution Specialist X3 jobs in California, MO, United States
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