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Grievance and Appeals Rep

The grievance and appeals representative is responsible for reviewing, analyzing, and processing policies associated to claim events to establish what the company’s liability and entitlement will be. Grievances are complaints made regarding providers or how a benefit decision was determined.

Job Duties and Responsibilities

  • Research complaints (grievances) and log and track the information as it moves through the clinical process or is tasked through internal contacts
  • Contact customers to collect information and communicate disposition of the case, document all interactions
  • Review cases to determine if it needs further review by a clinician
  • Use sound, fact-based decision-making skills to render a decision for non-clinical complaints
  • Use appropriate templates to complete necessary documentation for final appeals or grievance determination
  • Relay appeal or grievance information to members, providers, and internal/external parties within the appropriate timeframe
  • Create weekly statistical reports and prepares appeal hearings

Education and Qualifications

  • HS diploma or GED
  • 1+ year of work experience in a similar environment
  • Strong written communication skills, especially with grammar and spelling
  • Attention to detail and accuracy
  • Strong computer skills, must be able to run reports and manipulate/track/log data
  • Knowledge of Microsoft programs and CMS Guidelines
  • Experience with healthcare, medical, or pharmacy terminology is preferred

To be successful in the appeals and grievance representative role, you’ll need to possess strong analytical skills and effectively interact with other departments to attain original claims processing details.