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Grievance Resolution Specialist
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$25 - $31 an hour
Full-time
- 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 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.
- Maintains adequate information in Health's 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.
- 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.
Expired 2 days agoInactive Job
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