Grievance & Appeals Representative
Core
Review clinical documentation to determine if grievances, appeals, or further requests are warranted and deliver final determinations based on trained skillsets and partnerships with clinical parties.
Role type
Senior IC grievance and appeals representative
Builds
Final determinations on member and provider concerns
Domain
Healthcare insurance / Medicare & Medicaid
Deliverable
client delivery
Required skills
Clinical documentation review, Policy interpretation, Case investigation, Data analysis, Record keeping, Process explanation, Work prioritization, Team collaboration, Escalation management, Compliance adherence
Preferred skills
Medical claims processing, Inbound call center experience, Medical terminology, Medicare experience, Claims Administration System (CAS), Bilingual (English/Spanish), Geriatric population interaction
Technologies
Microsoft Word, Microsoft Excel, Claims Administration System (CAS)
Responsibilities
Assist members and providers with grievance and appeal inquiries; Investigate and resolve member and practitioner concerns; Document interactions and maintain accurate records; Research issues and gather information to support case resolution; Apply departmental policies and procedures to assigned work; Prioritize workload and manage tasks to meet service expectations
Seniority
Mid-level, hands-on IC