Position Overview: Prepare, analyze, and process provider and member grievances, appeals, and claim disputes for all lines of business within timelines set by regulators. Provide assistance and guidance to internal and external customers regarding grievance/appeals policies and procedures. Ensure customer satisfaction and help establish best practices.
Work Experience: Minimum three years of experience in the healthcare or health insurance industry. Customer service experience helpful; active problem resolution experience preferred.
Education, Certificates, Licenses: High school diploma or equivalent. Bachelor degree preferred.
Knowledge: Strong knowledge of Medicare/Medicaid benefits, program structure and HIPAA laws/regulations. Strong understanding of grievance/appeal regulations for Medicaid and Medicare programs. Proven history of exceeding timely complaint resolution and accuracy requirements. Basic-intermediate proficiency in Microsoft Office Applications including Word and Excel and call tracking software, mainframe and medical management software. Basic-intermediate knowledge of medical terminology and medical coding. Knowledge of claims, authorization methodology, and provider networks. Excellent business writing skills, requiring minimal assistance with written grievance resolutions and Independent Review Entity documentation. Excellent time management and diplomatic skills. Must be detail-oriented. Bilingual (Spanish) preferred.
Environment: Work inside in a general office setting with ergonomically configured equipment.
Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.
Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.
PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.