Appeals and Grievances Representative, Advanced - CalPERS

Full-time

El Dorado Hills, CA

Insurance Carriers and Related Activities

About the position

The Appeals and Grievances Representative is responsible for managing and resolving member appeals and grievances in a timely manner. This role involves answering inquiries, investigating issues, and providing explanations of health plan benefits to members and providers. Strong communication skills and the ability to work both independently and collaboratively are essential to meet compliance standards.

Responsibilities

• Answer telephone inquiries regarding member appeals.
• Respond to appeals and grievances and member reconsiderations.
• Research, review and resolve high level/high priority member grievances, appeals and complaints, while clarifying issues and educating customers in the process.
• Interpret and explain health plan benefits, policies, procedures and functions to members and providers.
• Prepare files for clinician review.
• Provide guidance to and act as authoritative source for others within the same skill set.
• Administer ongoing grievance tracking, trending, and reporting for assigned grievances.
• Review incoming appeals and grievances and determine which area to assign case to or reroute if the issue does not meet appeal or grievance criteria.
• Work in a collaborative manner with your team to meet compliance timeframes.
• Manage your time independently to ensure that all job duties are completed in a timely manner.

Requirements

• Requires a high school diploma or GED.
• Requires at least 4 years combined operations experience such as I&B, Claims, Customer Services, Regulatory Affairs; of which at least 1 year of direct experience is in Appeals/Grievances, or similar combination.
• Requires knowledge of Microsoft Systems such as Power Point, Excel, and Word.