Job Summary

Provides support in administration of the Appeals and Grievance process. Serves as a liaison between Members and the Plan with appeals regarding denied claims/services, referrals, membership and benefit issues and concerns regarding quality of care or service. PresentsMember appeals to the Plan Medical Staff and Center for Medicare/Medicaid Services contracted reviewer.
Job Duties


+ Prepares and facilitates Member appeals, complaints and grievances by communicating directly with Members, their Representatives, Vendors and Medical Providers and their Representatives to obtain the necessary information to complete the appeal process successfully within the time period allowed by regulation.

+ Investigates the full details of the appeal and complaints and grievances by consulting with, but not limited to, health care providers, legal services, internal medical staff and administration.

+ Provides timely and accurate documentation of...