Appeals Grievances Specialist II - Christus Health
Overview
Specialist owns member and provider grievance appeals processes ensuring compliance with CMS and TRICARE regulations while delivering high satisfaction outcomes. Researches complex cases and communicates resolutions effectively. Drives process improvements to enhance operational efficiency and member experiences.
What You'll Do11
- 1Research and resolve claim denials and member provider complaints
- 2Analyze grievance data to identify root causes and communicate findings
- 3Develop tracking reports to monitor dissatisfaction trends
- 4Recommend process enhancements to improve satisfaction and STAR ratings
- 5Summarize cases for management to facilitate fair decisions
- 6Integrate information from multiple sources to solve problems
- 7Maintain accurate responses and generate formal letters for appeals decisions
- 8Provide education on appeal processes to members and providers
- 9Ensure proper reimbursement according to Medicare and plan policies
- 10Follow HIPAA guidelines to protect PHI
- 11Attend regular team and department meetings
Requirements10
- 1Associate Degree preferred
- 2Three years customer service with managed care plans
- 3Two years appeal grievance experience with managed care
- 4Excellent research and analytical abilities
- 5Strong written and oral communication skills
- 6Ability to work flexible schedules including evenings and weekends
- 7Proficiency in word processing and spreadsheet software
- 8Knowledge of medical terminology and Medicare coding
- 9Experience with appeals and grievance systems
- 10Commitment to quality and regulatory compliance
Salary Insight
Salary not disclosed in listing
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