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  • El Dorado Hills, CA 95762

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Grievance / Appeals Representative

Kforce Finance and Accounting • El Dorado Hills, CA

Posted 28 days ago

Job Snapshot

Contractor
Competitive
Insurance
Finance

Job Description

RESPONSIBILITIES:

Kforce has a client seeking a Grievance/Appeals Representative in El Dorado Hills, California (CA). Responsibilities:
  • Researches and resolves member/subscriber grievances, appeals and complaints, and interprets and explains health plan benefits, policies and procedures to respondents
  • Researches, reviews and resolves high level/high priority member grievances, appeals and complaints, while clarifying issues and educating customers in the process
  • Interprets and explains health plan benefits, policies, procedures and functions to members and providers
  • Produces complex written correspondence to resolve member grievances, appeals and complaints
  • Administers ongoing grievance tracking, trending and reporting for assigned grievances
  • Evaluates all grievances for trend purposes and reports periodic and ad hoc trends to Risk and Quality Management departments
  • Coordinates next level grievance/appeal meeting with appropriate parties and forwards documentation to the review committee
  • Establishes and maintains cohesive relationships with assigned IPA partners through telephone, field work and written communication
Successfully exceed associate level responsibilities, in addition:
  • Researches, reviews and resolves high level/high priority member grievances, appeals and complaints, while clarifying issues and educating customers in the process
  • Interprets and explains health plan benefits, policies, procedures and functions to members and providers
  • Administers ongoing grievance tracking, trending and reporting for assigned grievances
  • Consistently performs established performance metrics

Job Requirements

REQUIREMENTS:

  • Typically, 1-2 years of related experience successfully demonstrating increasingly higher-level work
  • Generally, requires moderate experience in operations or customer service
  • Ability encompasses proficiency in the skills, internal procedures, and policies needed to satisfactorily complete the full range of assigned tasks
  • Able to make decisions based on demonstrated skill proficiency
  • Able to resolve most questions and problems, and refers only the most complex to higher levels
  • Strong knowledge of CUT, Custom View
  • Strong writing skills for document of member concerns and explanation of benefits
Kforce is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, pregnancy, sexual orientation, gender identity, national origin, age, protected veteran status, or disability status.

Job ID: FAWQG1808551
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