Process appeals and grievances, analyze, research, and provide comprehensive responses in accordance with established regulatory and accreditation guidelines.  Contact customers to gather information and communicate disposition of case. Conduct pertinent research in order to evaluate, respond to, and finalize case. Familiar with standard concepts, practices, and procedures for analyzing, interpreting data and applying contract and regulatory provisions.

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  Analyze, research, resolve and respond to confidential/sensitive complaints, appeals, grievances and organization determinations from members, member’s representatives, providers, media outlets, senior leadership and regulatory agencies with established regulatory and accreditation guidelines.
  


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  Make appeals complaints and grievance decisions and communicate decision to the claimant within regulatory and accreditation guidelines for timeliness, adhering to the strictest of timeframes for urgent and non-urgent requests, as imposed by the various federal and state laws.
  


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  Provide comprehensive appeals and grievances responses that support the decision and comply with regulatory and accreditation guidelines, and support the appeal decision by referencing specific and applicable language from the plan documents, certificates, riders, and summary plan descriptions, or the internal rules, guidelines and protocols, as appropriate.
  


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  Analyze, research, resolve and respond to high level inquiries, referrals, complaints, and appeals received from various regulatory agencies and other sources.
  


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  Maintain thorough knowledge of internal policies, procedures, regulations, charters for accurate resolution of appeals, complaints and grievances, including existing laws and regulations and new ones.
  


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  Identify business problems and initiate corrective measures; direct servicing issues to appropriate areas for corrective action.
  


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  Develop/prepare reports regarding the types/volumes/causes of inquiries received.
  


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  Develop and enhance workflows and business processes to improve customer service, decrease operational costs, resolve business issues, and improve overall efficiency.
  


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  Remain up-to-date in the use of internal systems as well as vendor systems.
  


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  Perform other duties as requested.
  

" Qualifications"

Medicare Advantage

1. Accountable for CMS Chapter 13, CMS Audit Compliance and Star Quality Measures: a.Member rights, b.Timely decisions about appeals, c.Fairness of the health plan's appeal decisions based on an independent reviewer


2. Data entry accuracy is required.


3. Full understanding of Medicare Advantage servicing environment, internal servicing partners and overall service center structure to include call center/servicing/escalations.

Departmental Preferences:

• Previous Medicare Advantage experience preferred. 


• Experience with claims preferred.