The Appeals and Grievances Specialist (AGS) is responsible for handling all Claims Appeals and Member Complaints and Grievances submitted on behalf of members via the health plans or regulatory agencies.
This role involves timely and accurately researching, managing and collecting and/or preparing responses to responding to all member claims appeals, complaints and grievances. AGS works together with multiple TMIPA and Cedars-Sinai department staff, health plan representatives, providers and others to research and collect requested information timely and submit to health plans as required.
The AGS tracks the status of all claims appeals and grievances and maintains complete and up-to-date records of all Appeals and Grievances with the system utilized for this purpose
Primary Duties and Responsibilities:
· Provides excellent customer service while responding to requests via phone, fax or email.
· Receives and responds to complaints and grievances received from Health Plans or regulatory agencies.
· Receives and responds to all claims appeal requests received from health plans or regulatory agencies.
· Collects all necessary documentation required to respond to complaints, appeals and grievances.
· Maintains complete, accurate, and up-to-date records and tracking logs of all activities related to claims appeals, complaints, and grievances.
· Prepares timely, complete, professional reports of all compliant and grievance activity and outcomes.
· Completes trends analyses of UM Appeals, complaints, and grievances.
· Accurately and completely documents all activity in the CRM documentation system within Tapestry, and/pr other documentation system(s)being employed for these purposes.
· Advises health plans, members, providers, and management of progress made towards resolution of member complaints, grievances, and claims appeals and advises of any problems encountered
- Work effectively with other departments such as Claims, Utilization Management, and Provider Relations as appropriate
- Ability to establish and maintain professional relationships with providers, health plans and members
Knowledge, Skills & Experience Required:
· Three (3) or more years’ experience in a medical group, hospital, IPA, or health plan
· Experience in health plan Appeals and Grievances strongly preferred
· Computer literate – strong working knowledge of Microsoft Office, Excel, PowerPoint, Outlooks, etc.
· Strong knowledge of medical terminology
· Ability to prioritize work to ensure required work flow.
· Excellent command of the English language is required.
· Strong Problem-solving skills
· Active and effective listener
· Strong organizational skills
· Strong time management skills
· Excellent verbal and written communication skills.
· High school diploma or general education degree (GED) required
· College degree preferred
Job Type: Full-time
Pay: $32.53 - $50.89 per hour
Expected hours: 40 per week
Benefits:
- Dental insurance
- Employee assistance program
- Flexible spending account
- Health insurance
- Life insurance
- Paid time off
- Prescription drug insurance
- Retirement plan
- Vision insurance
- Work from home
Schedule:
- 8 hour shift
- Day shift
- Monday to Friday
Work setting:
Work Location: Hybrid remote in Torrance, CA 90505