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Grievance Resolution Specialist
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$51,000 - $78,122 a year
Full-time
- The Grievance Resolution Specialist will be responsible for coordinating the grievance and appeal resolution process.
- The incumbent will respond to verbal and written grievances and appeals from members and providers relating to member eligibility and benefits, contract administration, claims processing, utilization management decisions and pharmacy and vision decisions.
- The incumbent will collaborate with internal departments such as Customer Service, Provider Relations, Pharmacy and Medical Management to identify factors necessary for the optimal resolution of Grievances and Appeals.
- 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.
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