Grievance/Appeals Representative // Thousand Oaks CA 91362

Job description

Business Grievance/Appeals Representative Location 1 WellPoint Way, Thousand Oaks CA 91362, USA Division Healthcare Contract 5 Months SUMMARY · Reviews, analyzes and processes claims in accordance with policies and claims events to determine the extent of the company's liability and entitlement. MAJOR JOB DUTIES AND RESPONSIBILITIES · Conducts investigation and review of customer grievances and appeals involving provision of service and benefit coverage issues. · Contacts customers to gather information and communicate disposition of case; documents interactions. · Generates written correspondence to customers such as members, providers and regulatory agencies. · Performs research to respond to inquiries and interprets policy provisions to determine the extent of company's liability and/or provider's/beneficiaries entitlement. · Responds to appeals from CS Units, Provider Inquiry Units, members, providers and/or others for resolution or affirmation of previously processed claims. · Ensures appropriate resolution to inquiries, grievances and appeals within specified timeframes established by either regulatory/accreditation agencies or customer needs. · Triages clinical and non-clinical inquiries, grievances and appeals, prepares case files for member grievance committees/hearings. · Summarizes and presents essential information for the clinical specialist or medical director and legal counsel. · Responds to oral and written complaints sent to the Office of the Chairman, President or Vice President Complaints. · Identifies barriers to customer satisfaction and recommends actions to address operational challenges. · Thoroughly documents and logs inquiry/appeal/grievance information on Grievance and Appeal Tracking systems for accurate tracking and analysis. · Good verbal and written communication, organizational and interpersonal skills. · PC proficiency. EDUCATION/EXPERIENCE · High school diploma or equivalent required. · 1 - 3 years health insurance business including customer service experience required. · Fully proficient in all areas of claims and customer service; may need guidance and supervision to complete some functions. If you are available and interested then please reply me with your “ Chronological Resume” and call me on (678)-405-3590 . Thanks & Regards, Ranadheer Murari | Team Recruitment | Mindlance, Inc. | W : 678 405 3590 ranadheerm@mindlance .com Mindlance is a national recruiting company which partners with many of the leading employers across the country. Feel free to check us out at .