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Medical Grievance and Appeals Specialist in El Dorado Hills, CA at Volt

Date Posted: 5/18/2019

Job Snapshot

Job Description

Volt has an immediate opening for a Grievance and Appeals Specialist in El Dorado Hills.  Our Client is a well-established, Health Care Insurance Company based in California.

The Grievance and Appeals Specialist will researches and resolves member/subscriber grievances, appeals and complaints, and interprets and explains health plan benefits, policies and procedures to respondents.

*Researches, reviews and resolves high level/high priority member grievances, appeals and complaints, while clarifying issues and educating customers in the process. Interprets and explains health plan benefits, policies, procedures and functions to members and providers.

*Produces complex written correspondence to resolve member grievances, appeals and complaints. Administers ongoing grievance tracking, trending and reporting for assigned grievances.

*Evaluates all grievances for trend purposes and reports periodic and ad hoc trends to Risk and Quality Management departments.

*Coordinates next level grievance/appeal meeting with appropriate parties and forwards documentation to the review committee.

*Establishes and maintains cohesive relationships with assigned IPA partners through telephone, field work and written communication.

Responsibilities:

*Researches, reviews and resolves high level/high priority member grievances, appeals and complaints, while clarifying issues and educating customers in the process

*Interprets and explains health plan benefits, policies, procedures and functions to members and providers

*Administers ongoing grievance tracking, trending and reporting for assigned grievances

*Consistently performs established performance metrics

Education/Requirements:

*Two or more year’s experience with Grievance and Appeals in a Healthcare Setting

*Ability encompasses proficiency in the skills, internal procedures, and policies needed to satisfactorily complete the full range of assigned tasks

*Makes decisions based on demonstrated skill proficiency

*Resolves most questions and problems, and refers only the most complex to higher levels

*Strong knowledge of CUT, Custom View

*Strong writing skills for document of member concerns and explanation of benefits

Volt is an Equal Opportunity Employer