What are the responsibilities and job description for the Resolution specialist position at Sunshine Enterprise USA LLC?
Company Summary : Our client is seeking a grievance resolution specialist, who will coordinate Grievance and appeal resolution process.
Position Summary : The ideal candidate shall hold the Associate’s degree, has at least 1 year of Grievances and Appeals or Claims experience in the healthcare field.
Work Duration : Monday Friday, 40 hours / week. Up to 6 months
Job Type : On-site
Position Responsibilities
- 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.
- 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.
- 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.
- Completes other projects and duties as assigned
Experience & Education
- Associate’s degree in business, health care administration or related field required.
- 1 year of experience in any of the following areas : Grievances and Appeals, Claims, Regulatory Compliance, Customer Service or related field required.
- Experience in health care practice standards for both government and commercial plans strongly preferred.
- Bilingual in English and one of the following languages : Arabic, Farsi, Chinese, Korean, Spanish, or Vietnamese
Necessary Attributes :
- Develop rapport and establish and maintain effective working relationships with leadership and staff and external contacts at all levels and with diverse backgrounds
- Work independently and exercise sound judgment.
- Communicate clearly and concisely, both orally and in writing.
- Work a flexible schedule; available to participate in evening and weekend events
- Organize, be analytical, problem-solve and possess project management skills
- Work in a fast-paced environment and in an efficient manner.
- Manage multiple projects and identify opportunities for internal and external collaboration.
- Motivate and lead multi-program teams and external committees / coalitions.
- Utilize computer and appropriate software (e.g., Microsoft Office : Word, Outlook, Excel, PowerPoint) and job specific applications / systems
Sunshine Enterprise USA is an Equal Opportunity Employer Minorities, Females, Veterans and Disabled Persons
PI255405758
Last updated : 2024-11-22
