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Job Status:
Full Time
Work Experience Required:
Up to 1 Year
Hours/Shifts:
Day (First Shift)
Education Required:
High School Diploma
Certification Required:
Unspecified
Weekends:
Not Required
Authorized to work in US:
Yes
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| Pay and Benefits |
Salary Range:
Unspecified
Benefits:
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Grievance/Appeals Rep I - 32709
WellPoint
Description
Reviews, analyzes and processes claims in accordance with policies and claims events to determine the extent of the company's liability and entitlement. 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.
Qualifications
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. Must be fully proficient in all areas of claims/customer service; Medicare experience, MCS System knowledge, strong claims background preferred. An understanding of the appeals process strong desired.
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