Member Appeals & Grievances Specialist
Location: Birmingham, Alabama
Work Schedule: This position will primarily work from the VIVA HEALTH headquarters in downtown Birmingham. After training has been completed, there would be an opportunity to work 1 day per week from home.
Job Summary
The Member Appeals & Grievances Specialist will analyze and resolve all Medicare appeals and grievances received from members, non-contracted providers and government entities. This role will coordinate a timely resolution according to state and federal guidelines and VIVA HEALTH policies and procedures. This position will participate in an on-call rotation to process appeals and grievances on weekends and holidays.
Why VIVA HEALTH?
VIVA HEALTH, part of the renowned University of Alabama at Birmingham (UAB) Health System, is a health maintenance organization providing quality, accessible health care. Our employees are a part of the communities they serve and proudly partner with members on their healthcare journeys.
VIVA HEALTH has been recognized by Centers for Medicare & Medicaid Services (CMS) as a high-performing health plan and has been repeatedly ranked as one of the nations Best Places to Work by Modern Healthcare.
Benefits
- Comprehensive Health, Vision, and Dental Coverage
- 401(k) Savings Plan with company match and immediate vesting
- Paid Time Off (PTO)
- 9 Paid Holidays annually plus a Floating Holiday to use as you choose
- Tuition Assistance
- Flexible Spending Accounts
- Healthcare Reimbursement Account
- Paid Parental Leave
- Community Service Time Off
- Life Insurance and Disability Coverage
- Employee Wellness Program
- Training and Development Programs to develop new skills and reach career goals
- Employee Assistance Program
See more about the benefits of working at Viva Health - https://www.vivahealth.com/careers/benefits
Key Responsibilities
- Process member and non-contracted provider Medicare Part C and Part D grievances and appeals according to federal and state regulations and internal, organizational policies and procedures.
- Collaborate with internal and external subject matter experts to obtain benefit and/or clinical opinions/interpretations.
- Identify training, process improvement, and other ways to maximize plan performance and customer satisfaction.
- Act as subject matter expert regarding grievances and appeals.
- Prepare for and participate in all required audits.
- Participate in on-call rotation on weekends and holidays.
REQUIRED QUALIFICATIONS:
- High School diploma or GED
- 1 - 3 years' experience in managed care, health care customer service, or appeals and grievances
- Excellent written and verbal communication skills, interpersonal skills, organization skills, and the ability to handle multiple tasks
- Ability to carefully follow processes in sequential order
- Ability to meet established productivity, schedule adherence, and quality standards
- Knowledge of computer platforms and applications of Microsoft Office
- Ability to use critical thinking skills to develop solutions to non-clinical issues using fact-based decision making
- Ability to work occasional planned and unplanned overtime to meet deadlines with minimal supervision
PREFERRED QUALIFICATIONS:
- Associates' Degree
- Experience working with the elderly population
- 1 - 3 years' experience processing Medicare appeals and grievances
- Knowledge of Medicare regulations
- Experience with administrative and/or coordinator positions with exposure to PHI