What are the responsibilities and job description for the Appeals AND Grievances Specialist I position at Insight Global?
The Customer Solution Center Appeals and Grievances Specialist I will support the Appeals and Grievances team to receive, investigate and resolve member and provider complaints and appeals; escalate complex issues or questions to leadership team as appropriate. The position is responsible for reporting noncompliance, adhering to company policy and procedures, including accreditation requirements, applicable federal, state and local laws and regulations. -Primary function of this role is to learn the specialty level appeals and grievances work by resolving less complex cases to ensure positive outcomes for members. (20%)-Supports the identification, investigation and resolve administrative complaints, simple appeals while adhering to Center for Medicare and Medicaid Services (CMS), California Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), Managed Risk Medical Insurance Board (MRMIB) and National Committee for Quality Assurance (NCQA) standards and regulations. (20%)-Intakes, acknowledges, prepares case files and routes complaints to appropriate internal departments and external business partners for investigation and resolution, exercising strong independent judgment. (20%)-Processes assigned cases accurately and in a timely manner per instructions. Escalates complex issues or questions to leadership as appropriate. (20%)-Actively participates in team meetings and provides recommendation for improvement as appropriate based on discoveries. (10%) Pay Range is $26-$33 an hour. We are a company committed to creating diverse and inclusive environments where people can bring their full, authentic selves to work every day. We are an equal opportunity / affirmative action employer that believes everyone matters. Qualified candidates will receive consideration for employment regardless of their race, color, ethnicity, religion, sex (including pregnancy), sexual orientation, gender identity and expression, marital status, national origin, ancestry, genetic factors, age, disability, protected veteran status, military or uniformed service member status, or any other status or characteristic protected by applicable laws, regulations, and ordinances. If you need assistance and / or a reasonable accommodation due to a disability during the application or recruiting process, please send a request to HR@insightglobal. com. To learn more about how we collect, keep, and process your private information, please review Insight Global's Workforce Privacy Policy : https : / / insightglobal.com / workforce-privacy-policy / . -Must be organized, detail oriented, able to exercise strong independent judgment; poses conflict resolution and persuasion skills. -At least 1 year of experience in Managed Care working with Medicare, Medi-Cal and other State Sponsored programs. -Experience working with firm deadlines, able to interpret and apply regulations. -Strong advocacy experience.
Salary : $26 - $33
