Grievance​/Appeals Representative​/Thousand Oaks CA

Grievance/Appeals Representative // Thousand Oaks CA 91362

Contract

Mindlance is a national recruiting company which partners with many of the leading employers across the country. Feel free to check us out at

Business Grievance/Appeals Representative

Location 1 WellPoint Way, Thousand Oaks CA 91362, USA

Contract 5 Months

• Reviews, analyzes and processes claims in accordance with policies and claims events to determine the extent of the company's liability and entitlement.

• 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 time frames 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.

• 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 .

Thanks & Regards,