Appeals and Grievances Speciialist

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.

Group 1001, and its affiliated companies, is strongly committed to providing a supportive work environment where employee differences are valued. Diversity is an essential ingredient in making Group 1001 a welcoming place to work and is fundamental in building a high-performance team. Diversity embodies all the differences that make us unique individuals. All employees share the responsibility for maintaining a workplace culture of dignity, respect, understanding and appreciation of individual and group differences.

Company Overview:

Clear Spring Health ("CSH") 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. CSH 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 and offers Medicare Prescription Drug Plans in 42 states plus DC.


Job Summary:

The Grievance and Appeals Coordinator has the overall responsibility for ensuring that grievances and appeals procedures are done in a timely, professional, member-focused manner, and is well documented. The position reports to the Director of Member Services.

Main Accountabilities:

  • Responsible for reviewing, researching, logging, tracking and processing all grievances and appeals for the plan 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.
    • Other duties as required.

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.
• Strong computer skills (keyboard proficient, quick data entry with a high level of accuracy).
• Must be able to work and act independently and be self-directed.

Qualifications:

  • • 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.