· Receives documents, investigates, and coordinates resolutions to Customer grievances for timely delivery to the Customer either orally, or in writing.
· Initiates case files for each grievance and ensures compliance with organization and the Centers for Medicare and Medicaid Services regulatory requirements.
· The Customer Service Lead Representative is responsible for intake, processing of oral and possibly written grievances, conducting root cause analysis as needed, creating an action plan, coordinating and communicating resolutions, as well as documenting systems in detail with case notes related to Customer grievances.
· At least 1 year experience within the health insurance industry required
· Excellent oral, written communication skills & critical thinking ability required
· Ability to track and manage case load effectively in call tracking system
· Must be able to work independently and under pressure related to tight time-frames
· Problem solving skills required
· Working knowledge of MS Word, Excel and the ability to pick-up and work in multiple computer systems is required
· Customer-centric mindset
· Requires 2 years experience in billing, claims, customer service or health insurance
· Preferred Requirements:
· Prior Medicare Advantage background preferred.
· Call center, Grievances or Appeals department experience preferred.
· High School Diploma or GED required.
Complex Problem Solving