Grievance and Appeal Representative - Remote

Overview

The Grievances & Appeals Representative 3 manages client denials and concerns by conducting a comprehensive analytic review of clinical documentation to determine if a grievance, appeal or further request is warranted.

In Short

• Manages client denials and concerns.
• Conducts analytic reviews of clinical documentation.
• Delivers final determinations based on trained skillsets.
• Performs advanced administrative and operational duties.
• Assists members and providers via phone or written communication.
• Requires independent initiative and judgment.
• Must have experience in the healthcare industry.
• Strong data entry and attention to detail skills.
• Intermediate experience with Microsoft Office tools.
• Must work a flexible schedule including possible overtime.

Requirements

• Minimum of 2 years of customer service experience.
• Experience in a metrics/production driven environment.
• Bilingual (English and Spanish) preferred.
• Knowledge of medical terminology.
• Ability to manage large volumes of documents.
• Excellent interpersonal skills.
• Associate or bachelor's degree preferred.
• Prior grievance and appeals experience is a plus.
• Experience with Medicare is beneficial.
• Ability to work from a dedicated space free from interruptions.

Benefits

• Competitive medical, dental, and vision benefits.
• 401(k) retirement savings plan.
• Paid time off including holidays and volunteer time.
• Short-term and long-term disability options.
• Life insurance and other opportunities.