Grievances and Appeals Coordinator

Medicare Advantage Health Plan Miramar, Florida


Description

Position at Clear Spring Health

Group1001 is a consumer-centric, technology-driven family of insurance companies on a mission to deliver outstanding value and operational performance by combining financial strength and stability with deep insurance expertise and a can-do culture. Group1001’s culture emphasizes the importance of collaboration, communication, core business focus, risk management, and striving for outcomes. This goal extends to how we hire and onboard our most valuable assets – our employees.

Company Overview:

Clear Spring Health is part of Group One Thousand One (“Group1001”), a customer-centric insurance group whose mission is to make insurance more useful, intuitive and accessible so that everyone feels empowered to achieve financial security. Clear Spring Health is dedicated to helping seniors protect their health and well-being by providing Medicare Advantage plans in select counties of Colorado, Illinois, North Carolina, and Virginia, plus Georgia and South Carolina through our affiliate, Eon Health.

Job Summary:

The role of the Grievances & Appeals Coordinator is to provide prospective members with an explanation of the various Medicare plans the company offers to consumers.  This role will answer inbound telephone inquiries from direct consumers, along with agents regarding the competitive Medicare plan offerings and options that consumers can purchase.  This position will be responsible for explaining different Medicare plans and can enroll consumers directly into the product of their choice.  There are many Medicare options for consumers to choose from, so we are seeking individuals that are excited about our products and can provide a high level of customer service that meets our service level agreements, while educating the customer accurately on our products. This is a highly customer focused position and requires that each caller's needs are fully understood and by taking the appropriate action to meet and exceed the customer's expectations.

This is a full time 40 hour a week opportunity, with overtime available.  The company offers a competitive benefits package, along with paid time off, tuition reimbursement and 401(k).  A competitive salary is offered.

Main Accountabilities:

  • Responsible for reviewing and processing member and provider grievances and appeals in accordance with Medicare regulations.
  • Resolve state and federal complaints, grievances and appeals.
  • Prepare case files for medical review as applicable.
  • Maintains electronic files of all documentation, and appropriate follow up documentation in member and provider call notes, or other computer system modules or databases as per current workflows.
  • Works directly with members assisting in problem resolution by utilizing established policies and procedures for problem identification and documentation.
  • Responsible for preparation of quarterly and annual reports on grievances and appeals.
  • Interacts with other departments including Member Services, Claims, Provider Relations, Pharmacy, and Utilization Management to resolve member and provider grievance and appeals.

 

  • Performs trending and analysis of grievances and appeals.
  • Generate reports including universe reports for audits and prepares audit samples for internal or Medicare audits.

Knowledge & Skills

  • Analytical ability with an affinity to detail, as well as the capability to handle heavy workloads and meet deadlines.
  • Willingness to support member service calls as needed in support of existing membership and products
  • Learning and updating one's knowledge of a wide variety of healthcare and Medicare product and plan information.
  • Ability to understand and compare specific competitor products against our portfolio of similar products.
  •  Explain Medicare program offerings in an informational and concise manner, and helping customers choose the best product options for them.
  • Easily adapt to change with new procedures or policies.
  • Excel in a performance driven culture that involves ongoing coaching and feedback from a variety of sources.
  • Ability to work within a call center environment and multi-task.

Requirements:

  • High School Diploma or equivalent, required.
  • 2+ years in customer service in a managed care environment
  • 2+ years experience in grievances and appeals
  • Experience with different software platforms (Microsoft Office: Outlook, Excel, Word, Skype), preferred.