Role & responsibilities
• Research and resolve written complaints submitted by consumers and physicians/providers
• Ensure complaint has been categorized correctly
• Obtain additional documentation required for case review
• Review case to determine if review by clinician is required
• Render decision for non-clinical complaints using sound, fact-based decision making
• Complete necessary documentation of final appeals or grievance determination using appropriate templates
• Communicate appeal or grievance information to members or providers and internal/external parties within the required timeframes
This is a challenging role with reliable impact. You'll need robust analytical skills and the ability to effectively interact with other departments to obtain original claims processing details.
You'll also need to effectively draft correspondence that explains the claim resolution/outcome as well as next steps/actions for the member.
Preferred candidate profile
Graduate
Minimum 1+ year of experience in US Healthcare claims process
Robust written communication skills including advanced skills in grammar and spelling
Proficiency with computer and Windows PC applications, which includes the ability to navigate and learn current and complex computer system applications
Preferred Qualifications
Experience with health care, medical, or pharmacy terminology