Grievance & Appeals Coord - Medicare Advantage

Blue Cross Blue Shield - Detroit, MI

Full-time - Entry Level

Detroit, MI

Insurance Carriers and Related Activities

About the position

The Grievance & Appeals Coordinator for Medicare Advantage is responsible for processing appeals and grievances, ensuring compliance with regulatory and accreditation guidelines. This role involves analyzing and researching cases, communicating with customers, and providing comprehensive responses to complaints and inquiries. The coordinator will also develop reports, enhance workflows, and maintain knowledge of internal policies and regulations to improve customer service and operational efficiency.

Responsibilities

• Process appeals and grievances in accordance with regulatory and accreditation guidelines.
• Contact customers to gather information and communicate case dispositions.
• Conduct research to evaluate and finalize cases.
• Analyze and resolve confidential complaints and appeals from various stakeholders.
• Make decisions on appeals and grievances and communicate them within regulatory timeframes.
• Provide comprehensive responses that support decisions and comply with guidelines.
• Maintain knowledge of internal policies and regulations for accurate resolution of cases.
• Identify business problems and initiate corrective measures.
• Develop reports on inquiries received and their causes.
• Enhance workflows to improve customer service and operational efficiency.

Requirements

• High School Diploma or GED required.
• Bachelor's Degree in English, Communications or related field preferred.
• Two years of customer service experience required.
• Two years of health insurance experience preferred.
• Strong project management skills preferred.
• Strong analytical, critical thinking, organizational, and problem resolution skills.
• Excellent verbal and written communication skills.
• Proficient in Microsoft Excel, Word, and Outlook.
• Knowledge of Blue Cross systems and operations preferred.
• Ability to protect confidentiality of corporate information.

Nice-to-haves

• Familiarity with health insurance state and federal regulations.
• Working knowledge of ACD telephone systems and call centers preferred.
• Knowledge of imaging technology preferred.
• Knowledge of OFIS, NCQA, and MTM guidelines preferred.
• Extensive knowledge of HMO/Health insurance terminology preferred.

Benefits

• Health insurance