Grievance Resolution Specialist - Sunshine Enterprise USA LLC

Company Summary: Our client is seeking a grievance resolution specialist, who will coordinate Grievance and appeal resolution process.

Position Summary: The ideal candidate shall hold the Associate’s degree, has at least 1 year of Grievances and Appeals or Claims experience in the healthcare field.

Work Duration: Monday ~ Friday, 40 hours / week. Up to 6 months

Job Type: On-site

Position Responsibilities

· Gathers pertinent information regarding the grievances and appeals received, including member or provider concerns, supporting information related to initial decision-making, new information supporting the grievance or appeal, or supplemental information required to evaluate grievances and appeals within regulatory requirements.

· Coordinates and participates in case discussions with operational experts to result in a final case disposition as needed.

· Evaluates case details, proposes recommendations, or makes decisions as applicable, ensures the organization’s decision is implemented according to the Grievance and Appeals policies and case resolution.

· Develops resolution letters and correspondence to members and providers.

· Communicates with internal and external customers to ensure timely review and resolution of grievances or appeals.

· Initiates referrals to the Quality Improvement department as applicable and facilitates responses to members.

· Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.

· Assists with health networks’ compliance process. Meets performance measurement goals for Grievance and Appeals Resolution Services (GARS).

· Identifies trends and root cause of issues, proposes solutions, or escalates ongoing issues to management.

· Assists the team in carrying out department responsibilities and collaborates with others to support short- and long-term goals/priorities for the department.

· Assists with health networks’ compliance process.

· Meets performance measurement goals for Grievance and Appeals Resolution Services (GARS).

· Identifies trends and root cause of issues, proposes solutions, or escalates ongoing issues to management.

· Completes other projects and duties as assigned

Experience & Education

· Associate’s degree in business, health care administration or related field required.

· 1 year of experience in any of the following areas: Grievances and Appeals, Claims, Regulatory Compliance, Customer Service or related field required.

· Experience in health care practice standards for both government and commercial plans strongly preferred.

· Bilingual in English and one of the following languages: Arabic, Farsi, Chinese, Korean, Spanish, or Vietnamese

Necessary Attributes:

• Develop rapport and establish and maintain effective working relationships with leadership and staff and external contacts at all levels and with diverse backgrounds
• Work independently and exercise sound judgment.
• Communicate clearly and concisely, both orally and in writing.
• Work a flexible schedule; available to participate in evening and weekend events
• Organize, be analytical, problem-solve and possess project management skills
• Work in a fast-paced environment and in an efficient manner.
• Manage multiple projects and identify opportunities for internal and external collaboration.
• Motivate and lead multi-program teams and external committees/coalitions.
• Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems

Sunshine Enterprise USA is an “Equal Opportunity Employer—Minorities, Females, Veterans and Disabled Persons”