Grievance/Appeals Analyst in Newark, NJ at DISYS

Date Posted: 7/25/2018

Job Snapshot

Job Description

Manages resolution of complaints and/or appeals that have been escalated to Horizon executives or regulatory entities within prescribed timeframes as mandated by the regulatory entity and per designated quality standards


Responsibilities:


•Assesses cause(s) of complaint/appeal, conducts thorough research of issue(s), determines required course of action and final disposition.


•Interacts with relevant parties to facilitate timely and accurate complaint/appeal resolution.


•Authorizes administrative exceptions which may involve claim adjustment resulting in payments at higher threshold levels so as to bring closure to the complaint/appeal.


•Contacts relevant party(ies) to acknowledge receipt of the complaint/appeal and uses probing techniques to clarify open issues, obtain additional relevant information and/or secure records necessary to complete investigation and bring issue to final resolution.


•Review business team representative/vendor representative telephone calls with customers to verify accuracy of information related to complaint/appeal.


•Develops customized, timely, accurate, detailed correspondence, for delivery to relevant party(ies), detailing case and final resolution. Correspondence may be used to educate party(ies) on benefit plan provisions and/or application of plan guidelines.


•Responds to regulatory entity or members/providers, both verbally and in writing, regarding issue details and final determination made by Horizon to close the complaint/appeal. Each response must be customized to the specific situation and address all issues presented by the member/provider.


•Partners with Legal Department to review and finalize appeal determinations.


•May prepare materials for and may attend case study meetings facilitated by designated internal or external parties.


•Other duties as assigned.

Job Requirements

Manages resolution of complaints and/or appeals that have been escalated to Horizon executives or regulatory entities within prescribed timeframes as mandated by the regulatory entity and per designated quality standards


Responsibilities:


•Assesses cause(s) of complaint/appeal, conducts thorough research of issue(s), determines required course of action and final disposition.


•Interacts with relevant parties to facilitate timely and accurate complaint/appeal resolution.


•Authorizes administrative exceptions which may involve claim adjustment resulting in payments at higher threshold levels so as to bring closure to the complaint/appeal.


•Contacts relevant party(ies) to acknowledge receipt of the complaint/appeal and uses probing techniques to clarify open issues, obtain additional relevant information and/or secure records necessary to complete investigation and bring issue to final resolution.


•Review business team representative/vendor representative telephone calls with customers to verify accuracy of information related to complaint/appeal.


•Develops customized, timely, accurate, detailed correspondence, for delivery to relevant party(ies), detailing case and final resolution. Correspondence may be used to educate party(ies) on benefit plan provisions and/or application of plan guidelines.


•Responds to regulatory entity or members/providers, both verbally and in writing, regarding issue details and final determination made by Horizon to close the complaint/appeal. Each response must be customized to the specific situation and address all issues presented by the member/provider.


•Partners with Legal Department to review and finalize appeal determinations.


•May prepare materials for and may attend case study meetings facilitated by designated internal or external parties.


•Other duties as assigned.

Digital Intelligence Systems, LLC. is an Equal Opportunity Employer, M/F/D/V. We do not discriminate against any employee or applicant because they inquired about, discussed, or disclosed compensation. Email recruitinghelp @ disys.com to contact us if you are an individual with a disability and require accommodation in the application process.