Job Summary

Serves to administer the Appeals and Grievance process as outlined by the Center for Medicare Services (CMS), Agency for Health Care Administration (AHCA), and the Florida Department of Financial Services (DFS).

Principal Duties & Responsibilities

• Act as a mediator between members and providers in order to provide satisfactory resolutions to complaints about services or treatment received. Each case may require thorough research and will include a documentation process to comply with state and federal applicable reporting requirements.

• The Grievances & Appeals Coordinator is responsible for notifying the member of outcome within a turnaround time defined by state regulations or the plan requirements (whichever is applicable).

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  Independently reviews the members' case file to determine if representative/appellant is authorized party and if complaint is valid.

• Prioritizes workflow on a consistent basis, applies key HIPAA and CMS guidelines in daily workflow, and meets turnaround times for assigned cases.

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  Partners with all service delivery functions (i.e. clinical, claims, billing and enrollment) to answer member questions/or works with others to resolve escalated issues

• Develops and delivers timely and professional communication dealing with complex issues at each step of the process to advise members of the progress and status of their issue.

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  Meets established productivity and quality standards in addition to attendance requirements.

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  Demonstrates problem solving, leadership, and conflict management skills in order to ensure a productive work environment and achievement of goals.

• Ensure compliance with local, state and federal laws, Medicare regulations and Aflac Dental and Vision policies and procedures.

• Displays a willingness to support the policies and procedures, and uses appropriate channels for change of such policies.

• Interact professionally with other employees, providers, members.

• Work independently while understanding the need to communicate and coordinate work efforts with other staff and organizations.

• Perform job responsibilities in compliance with all Aflac Dental & Vision Operating Policies and procedures.

• Complete required annual education courses within the expected timeframes.

• Be cognizant of and adhere to principles of Patient and Provider Rights and Responsibilities as outlined in Aflac Dental & Vision materials and policy documents

Education & Experience Required

• High School Diploma or Equivalent
• Four years of experience in customer service in healthcare setting handling complex inquiries and requests for service

Or an equivalent combination of education and experience

Job Knowledge & Skills

• Comfortable with coordinating among health plan, member and provider where necessary to arrive at a solution acceptable to all parties.

• Strengths include organization and planning, managing multiple demands, and achieving results.

• Analytical reasoning interprets and evaluates complex information, while identifying patterns and essential issues.

• Word processing, spreadsheets, and database software.

• Superb written and oral communication skills with particular emphasis on presentation skills.

• Proven ability to build consensus and work effectively within a cross-departmental team.

Competencies

• Acting with Integrity
• Communicating Effectively
• Pursuing Self-Development
• Serving Customers
• Supporting Change
• Supporting Organizational Goals
• Working with Diverse Populations