GP Grievances and Appeals Associate - ICONMA, LLC
Hopewell, VA
About the Job
GP Grievances and Appeals Associate
Location: Hopewell, VA/ Newark, NJ/ Hybrid
Duration: 6 Months
Description:
Manages resolution of (grievances) complaints and/or appeals within prescribed timeframes as mandated by the regulatory entity (State of NJ or CMS) and per designated quality standards for Government Programs Division.
Responsibilities:
Assesses cause(s) of complaint/appeal, conducts thorough research of issue(s), determines required course of action and final disposition.
Interacts with relevant parties to facilitate timely and accurate complaint/appeal resolution.
Authorizes administrative exceptions which may involve claim adjustment resulting in payments at higher threshold levels so as to bring closure to the complaint/appeal.
Contacts relevant party(ies) to acknowledge receipt of the complaint/appeal and uses probing techniques to clarify open issues, obtain additional relevant information and/or secure records necessary to complete investigation and bring issue to final resolution.
Review business team representative/vendor representative telephone calls with customers to verify accuracy of information related to complaint/appeal.
Develops customized, timely, accurate, detailed correspondence, for delivery to relevant party(ies), detailing case and final resolution. Correspondence may be used to educate party(ies) on benefit plan provisions and/or application of plan guidelines.
Responds to regulatory entity or members/providers, both verbally and in writing, regarding issue details and final determination made by client to close the complaint/appeal. Each response must be customized to the specific situation and address all issues presented by the member/provider.
Collaborate with internal supporting departments to review and finalize complaint/appeal determinations.
May prepare materials for and may attend case study meetings facilitated by designated internal or external parties.
Other duties as assigned.
Education/Experience:
College degree in Journalism, Communications, or related field, or equivalent in experience.
Requires five years of business experience which must include two+ years of correspondence and/or telephone customer service experience screening, investigating and examining inquiries.
Experience in claims processing necessary.
Ability to navigate the various claims and service operations systems.
Healthcare industry experience helpful.
Knowledge:
Knowledge of medical insurance claim processing and membership systems preferred.
Knowledge of medical terminology, COB, Medicaid/Medicare procedures preferred.
Knowledge of Facets or Ncompass preferred.
Knowledge of Claims Policy guidelines preferred.
Excellent knowledge of Microsoft Office Suite required.
Skills and Abilities:
Requires the ability to understand and use language correctly, to be determined by the Language skills test.
Requires keyboarding proficiency.
Requires the ability to perform basic arithmetical calculations.
Requires the ability to read, understand and interpret written materials.
Requires the ability to apply reason in order to determine the appropriate arithmetical operation for solving a problem.
Requires the ability to analyze information and to understand and apply rules and procedures.
Requires the ability to compose business letters.
Strong verbal and written communication including the ability to clearly communicate technical information to all levels of internal management and external stakeholder. Must be able to detail member-specific issues through the development of individual correspondence for each case, explaining all issues in a comprehensive, understandable fashion.
Requires strong telephone/interpersonal skills, strong conflict resolution skills and the ability to remain professional during difficult interactions with customers.
Excellent interpersonal skills (i.e. active listening).
Strong research, investigative, analytical, decision making and problem-solving skills.
Ability to perform in high pressure situations.
Ability to multitask.
Ability to manage and diffuse irate callers.
Time management skills.
Additional Skills:
Knowledge of Medicaid claim strongly desired
As an equal opportunity employer, ICONMA provides an employment environment that supports and encourages the abilities of all persons without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.
Location: Hopewell, VA/ Newark, NJ/ Hybrid
Duration: 6 Months
Description:
Manages resolution of (grievances) complaints and/or appeals within prescribed timeframes as mandated by the regulatory entity (State of NJ or CMS) and per designated quality standards for Government Programs Division.
Responsibilities:
Assesses cause(s) of complaint/appeal, conducts thorough research of issue(s), determines required course of action and final disposition.
Interacts with relevant parties to facilitate timely and accurate complaint/appeal resolution.
Authorizes administrative exceptions which may involve claim adjustment resulting in payments at higher threshold levels so as to bring closure to the complaint/appeal.
Contacts relevant party(ies) to acknowledge receipt of the complaint/appeal and uses probing techniques to clarify open issues, obtain additional relevant information and/or secure records necessary to complete investigation and bring issue to final resolution.
Review business team representative/vendor representative telephone calls with customers to verify accuracy of information related to complaint/appeal.
Develops customized, timely, accurate, detailed correspondence, for delivery to relevant party(ies), detailing case and final resolution. Correspondence may be used to educate party(ies) on benefit plan provisions and/or application of plan guidelines.
Responds to regulatory entity or members/providers, both verbally and in writing, regarding issue details and final determination made by client to close the complaint/appeal. Each response must be customized to the specific situation and address all issues presented by the member/provider.
Collaborate with internal supporting departments to review and finalize complaint/appeal determinations.
May prepare materials for and may attend case study meetings facilitated by designated internal or external parties.
Other duties as assigned.
Education/Experience:
College degree in Journalism, Communications, or related field, or equivalent in experience.
Requires five years of business experience which must include two+ years of correspondence and/or telephone customer service experience screening, investigating and examining inquiries.
Experience in claims processing necessary.
Ability to navigate the various claims and service operations systems.
Healthcare industry experience helpful.
Knowledge:
Knowledge of medical insurance claim processing and membership systems preferred.
Knowledge of medical terminology, COB, Medicaid/Medicare procedures preferred.
Knowledge of Facets or Ncompass preferred.
Knowledge of Claims Policy guidelines preferred.
Excellent knowledge of Microsoft Office Suite required.
Skills and Abilities:
Requires the ability to understand and use language correctly, to be determined by the Language skills test.
Requires keyboarding proficiency.
Requires the ability to perform basic arithmetical calculations.
Requires the ability to read, understand and interpret written materials.
Requires the ability to apply reason in order to determine the appropriate arithmetical operation for solving a problem.
Requires the ability to analyze information and to understand and apply rules and procedures.
Requires the ability to compose business letters.
Strong verbal and written communication including the ability to clearly communicate technical information to all levels of internal management and external stakeholder. Must be able to detail member-specific issues through the development of individual correspondence for each case, explaining all issues in a comprehensive, understandable fashion.
Requires strong telephone/interpersonal skills, strong conflict resolution skills and the ability to remain professional during difficult interactions with customers.
Excellent interpersonal skills (i.e. active listening).
Strong research, investigative, analytical, decision making and problem-solving skills.
Ability to perform in high pressure situations.
Ability to multitask.
Ability to manage and diffuse irate callers.
Time management skills.
Additional Skills:
Knowledge of Medicaid claim strongly desired
As an equal opportunity employer, ICONMA provides an employment environment that supports and encourages the abilities of all persons without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state, or local laws.
Source : ICONMA, LLC