Centers Plan for Healthy Living

Grievance & Appeals Fair Hearing Specialist

US-NY-Staten Island
4 months ago
ID
2017-1195
# of Openings
1
Category
Grievance & Appeals

Overview

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As in integral part of the Grievance and Appeals (G&A) Department, he G&A Fair Hearing Specialist lends their support in processing member-related appeals across CPHL's various lines of business.  Process includes gathering, documentation, tracking, and pursuing resolution of appeals and fair hearings in accordance with regulatory and organizational guidelines.

 

Responsibilities

Primary Responsibilities:

 

Ability to communicate effectively and professionally, both verbally and in writing.  Summarize information clearly, thoroughly, and quickly in writing.  use sound judgement, identify next steps to be taken and develop appropriate solutions.  Collaborate with multiple parties to solve problems; solve problems independently. Demonstrate PC skills and experience with the range of Microsoft Office products.

  • Schedule and represent CPHL at Grievance & Appeals hearings.
  • Conducts investigations and review of hearings involving provision of service and benefit coverage issues.
  • Significant contact with the Hearing Officers explaining case provisions, assisting in the preparation and filing of case materials and resolving complaints.
  • Actively seeks the involvement of the legal department or government affairs, whenever necessary, for clarification and supporting complaints.
  • Extensive travel and work between the various hearing and office locations.
  • Communicate case resolution to members and providers in accordance with regulatory expectations.
  • Keeps current with rules, regulations, policies and procedures relating to Plan member benefits, members rights and responsibilities, and Complaints and Grievances.
  • Ensures regulatory compliance, timeliness requirements and accurate standards are met.
  • Creates and maintains accurate records documenting the action sand rationale.  Develops correspondence communications the outcome of decisions with internal and external entities.
  • Assists with collecting and reporting data.
  • Performs research to respond to inquiries and interprets policy provisions to determine the extent of company's liability and/or/members/participants entitlement.
  • Identifies barriers and recommends actions to address operational challenges.
  • Maintains confidentiality of all protected health information in accordance with state, federal, and corporate guidelines.
  • Extensive travel required to attend court hearings.

 

Qualifications

Education and Experience:

  • Requires HS Diploma or equivalent, Bachelor's degree preferred.
  • 1-3 years' experience in health insurance business including customer service experience or any combination of education and experience, which would provide an equivalent background.
  • Good verbal and written communication, organizational and interpersonal skills.
  • Strong attention to detail and accuracy.
  • PC proficiency.
  • Knowledge of Medicare, Managed Care, and medical terminology preferred

 

Physical Requirements:

 

The physical requirements described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.  reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

 

The above statements are intended to describe the general nature and level of work performed by individuals assigned to the job classification. They should not be constructed as an exhaustive list of all responsibilities, duties and skills required.

 

 

 

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