Claims Specialist

Job Description :

Duties & Responsibilities :

• 80% - Program Support Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability. Maintains adequate information in systems; ensures data collection, summarization, integration and reporting, including case creation and management and events / activity tracking. Gathers pertinent information regarding the grievances and appeals received, including member or provider concerns, supporting information related to initial decision-making, new information supporting the grievance or appeal, or supplemental information required to evaluate grievances and appeals within regulatory requirements. Coordinates and participates in case discussions with operational experts to result in a final case disposition as needed. Evaluates case details, proposes recommendations, or makes decisions as applicable, ensures the organization’s decision is implemented according to the Grievance and Appeals policies and case resolution. Develops resolution letters and correspondence to members and providers. Communicates with internal and external customers to ensure timely review and resolution of grievances or appeals. Initiates referrals to the Quality Improvement department as applicable and facilitates responses to members according to Health policy.
• Participates in a mission-driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
• Maintains adequate information in Health’s systems; ensures data collection, summarization, integration and reporting, including case creation and management and events / activity tracking.
• Gathers pertinent information regarding the grievances and appeals received, including member or provider concerns, supporting information related to initial decision-making, new information supporting the grievance or appeal, or supplemental information required to evaluate grievances and appeals within regulatory requirements.
• Coordinates and participates in case discussions with operational experts to result in a final case disposition as needed.
• Evaluates case details, proposes recommendations, or makes decisions as applicable, ensures the organization’s decision is implemented according to the Grievance and Appeals policies and case resolution.
• Develops resolution letters and correspondence to members and providers.
• Communicates with internal and external customers to ensure timely review and resolution of grievances or appeals.
• Initiates referrals to the Quality Improvement department as applicable and facilitates responses to members according to Health policy.
• 15% - Administrative Support Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals / priorities for the department. Assists with health networks’ compliance process. Meets performance measurement goals for Grievance and Appeals Resolution Services (GARS). Identifies trends and root cause of issues, proposes solutions, or escalates ongoing issues to management.
• Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals / priorities for the department.
• Assists with health networks’ compliance process.
• Meets performance measurement goals for Grievance and Appeals Resolution Services (GARS).
• Identifies trends and root cause of issues, proposes solutions, or escalates ongoing issues to management.
• 5% - Completes other projects and duties as assigned.

Minimum Qualifications :

Preferred Qualifications :