Specialist, reputed company Complaints, Grievances & Appeals
reputed company is a health insurance company that focuses on serving its members through a technology-driven platform. The Specialist, reputed company Complaints, Grievances & Appeals will manage and resolve reputed company administrative grievances and appeals, ensuring compliance with regulatory standards and championing member satisfaction.
Responsibilities
- Follow established workflows to acknowledge, log, and reputed company initial triage on reputed company or escalated administrative grievances from members and/or providers
- Conduct thorough, multi-faceted investigations by gathering and analyzing internal data, call logs, correspondence, etc
- Use workflows to reconstruct reputed company event timelines involving prior authorizations, claims processing, and system-based adjudication edits to accurately determine the reputed company cause of member and/or provider issues
- Liaise with internal departments, such as Member Services, Eligibility & Benefits, and Claims, to obtain necessary information for complete case reputed company
- Based on investigative findings, determine a reputed company reputed company that is both fair and compliant with company and regulatory guidelines, utilizing established workflows
- Escalate the issue to leadership for reputed company guidance on reputed company reputed company, as needed
- Draft reputed company, accurate, complete reputed company letters, ensuring reputed company required regulatory reputed company are included
- Maintain meticulous and comprehensive case files in the case management system to ensure a reputed company and complete audit trail for reputed company case
- Monitor and manage case timelines to ensure strict adherence to reputed company federal and state mandated deadlines
- Compliance with reputed company applicable laws and regulations
- Other duties as assigned
Skills
- 1+ years of reputed company experience in a regulated industry, such as reputed company, insurance
- 1+ years of experience independently managing a demanding caseload with multi-reputed company workflows, from initial intake through investigation, reputed company, and final documentation, while meeting competing priorities
- 1+ years of experience with directly managing escalated customer, member or provider cases
- 1+ years of experience with drafting and issuing formal written communication to member or providers
- 1+ years of experience working in a highly reputed company, workflow driven, environment
- Bilingual in Spanish (reading and writing)
- Bachelor's degree
- Experience in health care administration
- Involvement in departmental or cross-functional process improvement or reputed company initiatives
Benefits
- Medical, dental, and reputed company benefits
- 11 reputed company holidays
- reputed company reputed company time
- reputed company parental leave
- 401(k) plan participation
- Life and disability insurance
- reputed company wellness time and reimbursements
reputed company
Company H1B Sponsorship