Customer Support Specialist - Remote

Kforce's client is looking for a Customer Support Specialist to join their team. This is a remote role, but candidates must reside in California.

Summary: The Customer Support Specialist's primary function is to learn the specialty level appeals and grievances work supporting the higher level position in this class series to ensure positive outcomes for members. It will support the Appeals and Grievances team to receive, investigate, and resolve member and provider complaints and appeals; escalates complex issues or questions to leadership team as appropriate.

Duties:

• Primary function of this role is to learn the specialty level appeals and grievances work by resolving less complex cases to ensure positive outcomes for members (20%)
• Supports the identification, investigation and resolve administrative complaints, simple appeals while adhering to Center for Medicare and Medicaid Services (CMS), California Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), Managed Risk Medical Insurance Board (MRMIB) and National Committee for Quality Assurance (NCQA) standards and regulations (20%)
• Intakes, acknowledges, prepares case files and routes complaints to appropriate internal departments and external business partners for investigation and resolution, exercising strong independent judgment (20%)
• As assigned process accurately and in a timely manner the assigned cases; Escalates complex issues or questions to leadership as appropriate (20%)
• Actively participates in team meetings and provide recommendation for improvement as appropriate based on discoveries (10%)
• Performs other duties as assigned (10%)