Grievance and Appeals Specialist - Remote

Overview

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.