Grievance/Appeals Representative // Cerritos CA 90703, USA

Business Grievance/Appeals Representative

Location 12898 Towne Center Drive, Cerritos CA 90703, USA

Division Healthcare

Contract 4 Months

SUMMARY

· Reviews, analyzes and processes claims in accordance with policies and claims events to determine the extent of the company's liability and entitlement.

MAJOR JOB DUTIES AND RESPONSIBILITIES

· Conducts investigation and review of customer grievances and appeals involving provision of service and benefit coverage issues.

· Contacts customers to gather information and communicate disposition of case; documents interactions.

· Generates written correspondence to customers such as members, providers and regulatory agencies.

· Performs research to respond to inquiries and interprets policy provisions to determine the extent of company's liability and/or provider's/beneficiaries entitlement.

· Responds to appeals from CS Units, Provider Inquiry Units, members, providers and/or others for resolution or affirmation of previously processed claims.

· Ensures appropriate resolution to inquiries, grievances and appeals within specified timeframes established by either regulatory/accreditation agencies or customer needs.

· Triages clinical and non-clinical inquiries, grievances and appeals, prepares case files for member grievance committees/hearings.

· Summarizes and presents essential information for the clinical specialist or medical director and legal counsel.

· Responds to oral and written complaints sent to the Office of the Chairman, President or Vice President Complaints.

· Identifies barriers to customer satisfaction and recommends actions to address operational challenges.

· Thoroughly documents and logs inquiry/appeal/grievance information on Grievance and Appeal Tracking systems for accurate tracking and analysis.

· Good verbal and written communication, organizational and interpersonal skills.

· PC proficiency.

EDUCATION/EXPERIENCE

· High school diploma or equivalent required.

· 1 - 3 years health insurance business including customer service experience required.

· Fully proficient in all areas of claims and customer service; may need guidance and supervision to complete some functions.

If you are available and interested then please reply me with your “Chronological Resume” and call me on (678)-405-3590.

Thanks & Regards,

Ranadheer Murari | Team Recruitment | Mindlance, Inc. | W: 678 405 3590

ranadheerm@mindlance .com