We are currently recruiting for an Appeals and Grievances Specialist for a client in Houston, Texas 77081.
•Establish a thorough understanding of the Medicare Managed Care Manual, Chapter 2, Chapter 13 and the Prescription Drug Manual, Chapter 18. •Perform comprehensive research related to the facts and circumstances of a member complaint, to include appropriate classification as a grievance, appeal or both, and implementation of applicable processes as mandated by CMS. •Perform comprehensive research related to the facts and circumstances of a member complaint filed by a regulatory agency otherthan CMS (i.e., Department of Insurance). •Responsible for making verbal contact with the member or authorized representative during the research process to further the member's complaint. •Responsible for the application of contract language, benefits and covered services from the Evidence of Coverage in researching and deciding the outcome in cases of grievances and appeals. •Responsible for reviewing research performed by operational areas to assure the appropriate resolution to the appeal or grievance has been achieved. •Responsible for the timely and accurate documentation of the grievance or appeal both electronically and in hard copy. •Responsible for timely and accurate written documentation to the member advising of the resolution of their issue. •Responsible for monitoring effectuation of all resolution/outcomes as a result of the appeal or grievance process. •Complies with all guidelines established by the Centers for Medicare and Medicaid (CMS) and guidelines set forth by other regulatory agencies, where applicable, and defined in the Corporate and department policies. •And all other duties assigned by the manager and/or supervisor.
•Professional verbal and written communication skills, with the ability to clearly articulate thoughts and ideas •Organizational skills with the ability to handle multiple tasks and/or projects at one time •Customer service skills with the ability to interact professionally and effectively with providers, third party payers, physicians, and staff from all departments within and outside the Company •Analytical and interpretation skills including departmental, utilization, financial and operations data •Decision-making skills with the ability to investigate and weigh alternatives and select the course of action that provides the greatest benefit to the organization •Creative thinking skills with the ability to ask the needed bigger-picture questions that lead to process and team improvements •Time management skills with the ability to prioritize and schedule daily activities for the most efficient use of time •Problem solving skills with the ability to look for root causes and implementable, workable solutions •Interpersonal skills with the ability to work in a fast-paced environment and participate as an independent contributor with little supervision or as an active team member depending on the situation and needs •Must have a track record of producing work that is highly accurate, demonstrates attention to detail, and reflects well on the organization
Required Experience •High School diploma or equivalent and/or continuing education •Minimum of one year of experience in a health insurance plan Appeals and Grievance area, preferably in a Medicare setting •Minimum of two years of experience in claims, enrollment, billing or customer service in a health insurance plan setting •Software experience preferred -- EZCap, HEMIS, HIMS, Facets •Personal computer experience should include working with Microsoft Word, Excel, PowerPoint and Outlook at the intermediate level at a minimum
Your resume is just an introduction, not the whole story. At Gentech our recruiters take the time to learn about you, your skills, and your career goals. Whether you're looking for consulting, consult-to-hire, or direct placement, we'll provide you with career options, prepare you for interviews, and maintain our relationship with you after you accept a position to be sure you're satisfied.
Gent...ech is an IT Consulting and Placement firm in Pittsburgh, PA. We work hard to be your partner and we take on your career/hiring needs as our own. We strive to earn and maintain the trust of the people with whom we work. Gentech's benefits are second to none.
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