Grievance/Appeals Rep II
Core
Reviews, analyzes, and processes claims events to determine company liability and entitlement for service and benefit coverage issues.
Role type
Senior IC Grievance and Appeals Representative
Builds
Administrative decisions and case files for member grievance committees and external reviews
Domain
Healthcare insurance claims and appeals
Deliverable
client delivery
Required skills
Claims knowledge, policy research, eligibility verification, written correspondence, case file preparation, triage, data base management
Preferred skills
Behavioral health experience, multi-priority management, analytical skills, facilitation skills
Technologies
PC, word processing, spreadsheets
Responsibilities
Conduct investigations and reviews of customer grievances and appeals; contact customers to gather information and communicate case dispositions; generate written correspondence to members, providers, and regulatory agencies; research administrative aspects of appeals; make decisions on administrative appeals with well-documented guidelines; prepare files for internal or external review; triage clinical and non-clinical inquiries; summarize information for clinical specialists and legal counsel
Seniority
Mid-level, hands-on IC