Grievance Resolution Specialist - TEMP

Job Description

TEMP - Grievance Resolution Specialist

Job Summary

The Grievance Resolution Specialist coordinates the Grievance and Appeal resolution process, responds to verbal and written Grievances and Appeals from members and / or providers relating to member eligibility and benefits, contract administration, claims processing, utilization management decisions, and pharmacy and vision decisions. The incumbent has frequent external contact with members and families, healthcare providers, health networks, third-party administrators, and regulators. The incumbent collaborates with internal departments such as Customer Service, Provider Operations, Pharmacy, and Medical Management to identify factors necessary for the optimal resolution of Grievances and Appeals.

Position Responsibilities

• Maintains adequate information in our health systems; ensures data collection, summarization, integration, and reporting which includes case creation and management and events / activity tracking.
• Gathers pertinent information regarding the grievances and appeals received, including, but not limited to, 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 / or participates in case discussion with operational experts to result in a final case disposition as needed.
• Evaluates case details, proposes recommendations, or makes decisions as applicable; ensures organization 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 Quality Improvement department as applicable and facilitates responses to members according to our health policy.
• Assists with Health Networks' compliance process.
• Identifies trends and root cause of issues; proposes solutions or escalates ongoing issues to management.
• Meets performance measurement goals for Grievance and Appeals Resolution Services.
• Completes other projects and duties as assigned.

Possesses the Ability To :

Experience & Education

Preferred Qualifications

Knowledge of :

At Sunshine Enterprise USA LLC, we firmly believe that our employees are the heartbeat of our organization and we are happy to offer the following benefits :

Sunshine Enterprise USA is an "Equal Opportunity Employer-Minorities, Females, Veterans and Disabled Persons"