Customer Service Lead Representative

Notes:

Training: Monday - Friday 8AM - 5PM CST

Shifts between Monday - Friday 8AM- 5ProductST; candidates can pick their shifts once they are out of training

OT is available once training is complete and candidate performance meets expectations, upon approval

100% WAH - 50 states

Duties

Candidates can be sourced from across the US as long as they're able to support the CST schedule.

Candidates must have reliable, high-speed internet connection and have a quiet and private working environment.

Time off will not be approved for the first 8 weeks - any candidates with time off within this time frame will not be able to move forward.

Candidates are expected to arrive on-time, everyday to work.

After training and once acclimated, workers will be expected to adhere to the below standards.

• Metric Driven: Closing 10 cases/day (goal)
• Quality Metric: 95% or higher during Audits
• DPA %: Needs to be 75% or higher (Active during working hours)
  
  

The Grievance team manages Client Medicare/Medicaid grievances that are presented by our members or their representatives pertaining to the authorization of or delivery of clinical and non-clinical services. Grievance works in collaboration with divisions within and outside the organization to resolve issues in a timely and compliant manner.

Grievances coordinator position is focused on the processing of Medicare customer grievances. This associate may screen incoming complaints received orally or in writing, conducting root cause analysis as needed, creating an action plan, coordinating and communicating resolutions, as well as documenting systems in detail with case notes related to Customer grievances with in CMS guidelines.

Top Skills:

Written communication

Critical Thinking

Microsoft Office Knowledge

• Minimium requirement: 1 year of G&A(Grieveances and Appeals) and/or 1 year or more of Customer Service at a health insurance company
• Bilingual in Spanish is preferred but not required
• Strong written and verbal communication skills, PC proficiency to include Microsoft office products.
• One year of health insurance/managed care experience performing Appeals and Grievances functions.
• Will consider managed care associates with three years of experience in customer service, call center or claims processing skills and knowledge of healthcare delivery.
• Demonstrated ability to manage large caseloads and effectively work in a fast-paced environment.
• Demonstrated written communication skills, time management, priority setting, problem solving and organizational skills.
• Demonstrated ability to converse with and collaborate with physicians and physician personnel.
• Ability to identify and define problems, collect data/information, establish facts, and draw valid conclusions and provide resolution.
• Ability to track and manage case load effectively in Grievance tracking system
• Must be able to work independently and under pressure related to tight time-frames
• One year of health insurance/managed care experience knowledge of healthcare terminology preferable.
• Intermediate PC Skills
• Previous experience working in a remote setting is preferred.
  
  

Role and Responsibility:

• Grievance Coordinator is responsible for corresponding with members, providers and regulators regarding decisions and actions.
• Works collaboratively with the Claims, Customer Service, Appeals, and Medical Management Departments.
• Communicate, collaborate and cooperates with internal and external business partners.
• Adheres to all Compliance/Program Integrity requirements and complies with HIPAA Regulations.
• Promotes individual professional growth and development by meeting requirements for mandatory/continuing education and skills competency.
• Supports department-based goals which contribute to the success of the organization
  
  

Education

• A high school diploma and two years in a Medicare, Medicaid managed care environment investigating and resolving Grievances