Appeal and Grievance Intake Specialist

Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market-driven rates. The salary range displayed has not been adjusted for geographical location.

Benefits

• Medical, Dental & Vision coverage
• Retirement Plan
• Generous time off including Paid Time Off, Holidays, and Volunteer time off
• Incentive Plan
• Tuition Reimbursement

Responsibilities

• Handle all administrative functions of the Appeals and Grievance (A&G) process including intake, logging, tracking, and status follow-up of all appeal and grievance requests.
• Review recorded calls relating to appeals and grievances and prepare written transcripts, as appropriate.
• Effectively route intake/triage for fulfillment, independently evaluate information to determine correct categorization, and perform timely data entry to support follow-up inquiries received in the Service Center.
• Track all open A&G files to ensure responses are completed within the timeframe required by alliance performance requirements, law, regulation, policy, or other requirements.
• Assist with the communication of A&G determinations by preparing template letters for members/providers, prepare weekly department activity reports and monthly production reporting, and scan A&G files for record retention.
• Identify potential issues when preparing and reviewing reports for discussion with department leadership.
• Create and maintain electronic and hard copy paper files in accordance with all regulatory requirements.
• Perform other duties as assigned.

Requirements

• Minimum 2+ years of experience in customer service within a dental, medical, or Managed Care industry.
• High school diploma or equivalent.

Skills

• Self-directed and strong organizational skills to meet departmental goals with minimal supervision.
• Ability to clearly interpret written inquiries and complaints and produce written documents.
• Excellent business writing and comprehension skills, including spelling, grammar, and punctuation.
• Strong verbal communication skills.
• Demonstrated knowledge of Microsoft Office Suite.

Physical Demands

While performing the duties of this job, the employee is regularly required to talk or hear. The employee frequently is required to stand; walk; use hands to finger, handle or feel; and reach with hands and arms.