Member Advocacy & Appeals Support Specialist II

Remote

Employment Type

Full-time

Exempt or Non-Exempt

Non-exempt [Non-ex.]

Worksite Location (In-Office):
Honolulu

Pay Range: $42,000 - $78,000

Note:

Individuals typically begin between the minimum to middle of the pay range

Provides high level administrative and clerical support to Member Advocacy and Appeals department.

• Diploma and one year of related experience; or an equivalent combination of education and related work experience.
• Strong verbal and written communication skills
• Basic working knowledge of Microsoft Office applications including Word, Excel, and Outlook.

• Handles the intake processes for all Department cases that involve complex confidential issues in a highly time sensitive environment.
• Intake of member and provider calls, faxes, email correspondence, and internal referrals; evaluation of information to determine best course of action; and follow-up with Department staff and internal departments to ensure accurate case creation are completed consistent with information relayed to members/providers and within timeframe required by law, regulation, policy, or other requirement.
• Conduct analysis of sensitive member and provider appeals, inquiries and grievances and applies internal policies and procedures, contractual provisions, and regulatory requirements.
• Triage cases to resolve them upon initial inquiry/intake to best service members and reduce cases escalated to Case Resolution Specialists.
• Creates and maintains accurate electronic case files for appeals and grievances from members and providers within the scope of internal policies and procedures, and regulatory timeframe requirements.;.
• Identifies potential issues when preparing and reviewing electronic cases including case file and program database entry and discusses these with the department supervisor or coordinator.
• Updates electronic case folder and computer program database.
• Handles internal and external customer service calls regarding member or provider appeals or grievance requests.
• Is able to handle complex issues and requests by listening for understanding and communicates appropriately and professionally with internal/external customers.
• Is able to identify what the caller is requesting, and asks questions for understanding, to offer excellent customer service experience.
• Performs all other miscellaneous responsibilities and duties as assigned or directed.