The Grievance and Appeals Specialist position is responsible for reviewing and resolving members' and/or providers' complaints and communicating resolution to members or authorized representatives and/or providers in accordance with the standards and requirements established by the Centers for Medicare and Medicaid Services (CMS).

In Short

Be able to process both appeals and grievances.
Have a strong Medicare Appeals processing background.
Logging, tracking, and ensuring completion of all appeals, direct member reimbursements, and grievance cases in compliance with CMS standards.
Manage tracking database to ensure the integrity of data and that all assigned cases are captured and maintained appropriately.
Prepare documentation and transmit appeals of clinical denials to the appropriate professional for review and tracking review completion to ensure final closure of the associated case.
Participate in all aspects of the direct member reimbursement, grievance & appeal process, specifically intake, triage, coordination, and documentation.
Research, investigate, and resolve administrative aspects of appeals and/or grievances from Zing members and related outside agencies.
Assures the accuracy, timeliness, and appropriateness of all grievances and appeals according to state and federal, and Zing guidelines.
Collaborate with internal departments as necessary to ensure the timely resolution of all grievances and appeals.
Document the results of complaints and appeals and dispositions at all levels.

Requirements

High school diploma or GED with at least two years of college or equivalent experience.
Strong communication skills both oral and written.
Strong organizational skills, consistent attention to detail, and independent problem-solving skills.
Minimum of two (2) years of experience in a Managed Care (Health Plan) environment performing appeals reviews/investigation or data analysis.
Knowledgeable in various operational areas such as customer service, provider service, claims processing, utilization management, pharmacy, and dental in a managed care setting.
Ability to perform multiple tasks simultaneously, work under pressure, and meet critical deadlines.
Must possess a high degree of professionalism and business ethics.
Knowledge of medical terminology, insurance terminology, and benefit plan coverage and exclusions.

Benefits

Assists with interdepartmental issues to help coordinate problem-solving in an efficient and timely manner.
Assist the Manager of Grievance and Appeals in establishing and maintaining policies and procedures, compliance reporting, and training material.
Manage workload volume, ensuring accuracy and compliance with scheduled deadlines.
Perform other related duties as assigned.