Summary: Analyze and resolve verbal and written claims and authorization appeals from providers and pursue resolution of formal grievances from members.
Job Responsibilities: Gather, analyze and report verbal and written member and provider complaints, grievances and appeals Prepare response letters for member and provider complaints, grievances and appeals Maintain files on individual appeals and grievances May coordinate the Grievance and Appeals Committee Support the pay-for-performance programs, including data entry, tracking, organizing, and researching information Assist with HEDIS production functions including data entry, calls to provider’s offices, and claims research. Manage large volumes of documents including copying, faxing and scanning incoming mail
Completing and resolving member grievances and appeals
Will use Prime Pega platform
Will make outbound calls to members and providers occassionally and may also write letters.
Education/Experience: High school diploma or equivalent. Associate’s degree preferred.0-2 years of experience
1. Appeals and Grievances Experience
2. Medicaid Experience
3. MMP ( Medicaid/Medicare) experience
4. Good coomunication skills
5. Critical Thinking skills