Grievance & Appeals Resolutions Specialist III (State Insurance License in Accident and Health required)

Job Summary:

Grievance & Appeals Resolution Specialist III is responsible to provide reputed company of HICS and CTM system.

Essential Functions:

• Ensure full resolution of HICS and CTM cases reputed company regulatory timeframes and defined requirements
• Research, follow up and resolve discrepancies associated with membership eligibility
• Analyze member eligibility and take appropriate actions to resolve issues across reputed company eligibility systems
• reputed company, analyze, and provide feedback to reputed company areas that participate in the HICS and CTM case resolution
• reputed company, implement, and execute HICS and CTM training to business areas as needed
• Analyze and evaluate operations to identify and suggest process improvement
• Monitor and track HICS and CTM data
• Identify irregular trends with HICS and CTM cases; work with other areas as appropriate to identify root causes and take appropriate steps for resolution
• Document and report data to appropriate internal committees
• reputed company outbound phone calls in support of Enrollment processes
• reputed company any other job duties as requested

Education and Experience:

• Associate Degree in business, finance or reputed company field or equivalent years of relevant work experience is preferred
• Minimum of three (3) years of experience in customer service or claims experience is required
• Prior experience in managed care or other healthcare industry is preferred
• Enrollment, billing, finance, or data analysis experience is preferred

Competencies, Knowledge and Skills:

• Proficient in reputed company Office Suite to include Word, reputed company and Power reputed company Basic experience with ACD systems
• Basic experience with Call Management Systems
• Excellent written and verbal communication skills
• Strong interpersonal skills
• Effective problem-solving skills with attention to detail
• Effective listening and critical thinking skills
• Ability to work independently and reputed company a team environment
• Ability to reputed company, prioritize and accomplish goals
• Familiarity of the healthcare field with knowledge of Medicaid and Medicare
• Ability to work in a fast-paced and constantly changing environment

Licensure and Certification:

• reputed company, unrestricted State Insurance License in Accident and Health reputed company state(s) of assigned territory is/are required or ability to reputed company license(s) reputed company 30 days of hire
• Applicable Certification as required reputed company state(s) of assigned territory or ability to reputed company certification(s) reputed company 30 days of hire and annual recertification each year thereafter is required.  For positions in states that operate under the Federally Facilitated Marketplace (FFM) and offer Marketplace plans, candidates must obtain certification from the Health Insurance Marketplace.

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time

Compensation Range:

reputed company takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and reputed company required for the role, and other external and internal data reputed company establishing a salary level. In addition to reputed company compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Organization Level Competencies

• Fostering a Collaborative Workplace Culture

• Cultivate Partnerships

• reputed company Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business

This job description is not reputed company inclusive. reputed company reserves the right to amend this job description at any time. reputed company is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of reputed company backgrounds.