This position is responsible for receiving, researching and facilitating resolution of member/provider grievances, appeals and complaints. Determines applicable compliance criteria based on Medicaid, Medicare and Commercial regulations and ensures workflow is managed to compliance turn around times. Interprets and explains the company’s benefits, policies and procedures to members and providers as they relate to grievances, appeals and complaints. Tracks and monitors movement of assigned cases through functional units and systems while ensuring that resolution meets established timelines.
Communicates with members/providers either verbally or in writing as required and within established timelines to acknowledge and resolve grievances, appeals and complaints. Administers ongoing grievances, appeals and complaint tracking, trending and reporting for regulatory agencies and maintains secure and efficient processes for regulatory record keeping of related documents and the correspondence and reporting needs that support these requirements, with the ability to produce all required documents for audits and regulatory review. Evaluates all grievances, appeals and complaints for trend purposes, and reports findings to management. Establishes and maintains cohesive and successful interdepartmental relationships within the organization.
This position will support all lines of business for the organization.
Neighborhood is an Affirmative Action and Equal Opportunity Employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, national origin, genetic information, age, disability, veteran status or any other legally protected basis.
Neighborhood is committed to ensuring individuals with disabilities and/or those who have special needs participate in the workforce and are afforded equal opportunity to apply for jobs. If you would like to contact us regarding the accessibility of our Website or need assistance completing the application process, please contact us at firstname.lastname@example.org.
Neighborhood is an EOE M/F/D/V and an E-Verify Employer