Research and respond to member and provider appeals, complex complaints, grievances and inquiries relating to all aspects of health plan coverage consistent with contract, regulatory and/or accreditation requirements. Seeks management guidance and supervisor/manager direction as needed.

• Conducts critical analysis of highly complex and sensitive member and provider appeals, inquiries and grievances and applies internal policies and procedures, contractual provisions, and regulatory requirements.
  
  • Secures information from internal and external resources to resolve issues.
  • Assists Supervisor and Coordinator in working as a liaison with providers, members and internal decision makers in representing HMSA objectives, goals, and expectations for meeting contractual, regulatory, and accreditation requirements.
  • Negotiates/resolves sensitive issues with internal and external parties.
  • Takes all facts and research from internal and external resources and presents a full explanation of the member's or provider's position and concerns to management and decision makers.
  • Triages cases to resolve them upon initial inquiry to best service the member as well as minimize the number of cases escalated to senior management and executives.

• At the direction and supervision of management, participates on cross departmental committees and other internal meetings to identify, clarify, research, and resolve inquiries and issues.
  
  • Identifies when changes to policies and procedures are needed based on case resolutions, statutory or regulatory changes, or accreditation requirements.
  • Proposes changes to management based on identification and analysis.
  • Analyzes and identifies issues that may require multiple department efforts to resolve.
  • Presents recommendations to internal committees, subgroups and executive management for decision making purposes as it relates to cases after discussion and approval from Supervisor and Coordinator.
  • Assists with the implementation of resulting decisions for change/resolution.
  • Assists supervisor/manager in responding to internal investigations, reviews, and audits; regulatory inquiries; and accreditation related audits.
  • Assist internal customers with complex member/physician inquiries with guidance and direction from management.

• Identifies member problems, member education needs, or trends and report these to manager, as well as recommend resolution. Takes a proactive role in reviewing, digesting and communicating any new regulation, standard, business change, etc. affecting the member advocacy and/or appeals process. At direction of management, assists in the coordination of changes among departments.

• Performs quality assurance of case documents and assists Supervisor and Manager with various corporate activities.

• Performs all other miscellaneous responsibilities and duties as assigned or directed.

• Bachelor's degree and one year of related work experience; or equivalent combination of education and related work experience.

• Effective verbal and written communication skills

• Problem identification and resolution skills

• Basic knowledge of Microsoft Office applications. Including but not limited to Word, Excel, Outlook, and Power Point.