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Grv/Appeals Associate-25050-1 MPK
Monterey Park, California | Contract
EXCITING CONTRACT POSITION IN MONTEREY PARK FOR MEMBER REIMBURSEMENT COORDINATOR!
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. Identifies issues, and with assistance, executes corrective action Intake Queue. Complaint files Process QOC files. EID -Expedited Initial Determinations Performs established performance metrics
1 year of experience within claims or utilization management
Strong MS Office including data entry and calendaring
Working knowledge of ICD10-CM, HCPCS and CPT codes