Responds to written and/or verbal grievances, complaints and appeals submitted by members and providers in accordance with the regulations of the NCQA, CMS, State of NY and other regulations. Types of correspondence handled by the individual will include, but not limited to, correspondence, payment disputes, complaints/grievances, and appeals.
o Provides written acknowledgment of all member and provider correspondence. Reviews all receipts and applies various regulations to appropriately classify the inquiry. Makes critical decisions regarding research and investigation to appropriately categorize and resolve all inquiries.
o Conducts thorough investigations of all related member and provider correspondence by analyzing all the issues involved and obtaining responses and required information from internal and external entities. o Interfaces with HIP departments, Delegated entities, Medical Groups and Network Physicians to ensure timely resolution of cases.
o Prepares written responses to all member and provider correspondence that appropriately address the complainant's issues and are structurally accurate.
o Monitors daily and weekly pending reports and personal SAWS worklists, as well as make necessary follow-up calls to internal and external entities to ensure that cases are completed on or before the applicable timeframe.
o Classifies and codes ESaws inquiries appropriately, and enters all actions taken in investigation for auditing and reporting purposes. Perpares cases for medical and administrative review detailing the findings of their investigation for consideration in the plan's determination.
Knowledge, Skills and Abilities:
o Excellent product knowledge.
o Excellent problem-solving and analytical skills.
o Ability to work under pressure and deliver
o Excellent communication skills (written and verbal).
o Excellent organization skills
Miniumum of 2 years work experience in an HMO environment is required, or two years of college with a minimum of 4 years work experience.
Group Health Incorporated (GHI) - 17 months ago
EmblemHealth is set on being the mark of good health in the Northeast. The not-for-profit company provides health...