Grievance & Appeals Resolutions Specialist III (State Insurance License in Accident and Health required)

Job Summary:

Grievance & Appeals Resolution Specialist III is responsible to provide oversight of HICS and CTM system.

Essential Functions:

• Ensure full resolution of HICS and CTM cases within regulatory timeframes and defined requirements
• Research, follow up and resolve discrepancies associated with membership eligibility
• Analyze member eligibility and take appropriate actions to resolve issues across all eligibility systems
• Oversee, analyze, and provide feedback to all areas that participate in the HICS and CTM case resolution
• Develop, implement, and execute HICS and CTM training to business areas as needed
• Analyze and evaluate operations to identify and suggest process improvement
• Monitor and track HICS and CTM data
• Identify irregular trends with HICS and CTM cases; work with other areas as appropriate to identify root causes and take appropriate steps for resolution
• Document and report data to appropriate internal committees
• Make outbound phone calls in support of Enrollment processes
• Perform any other job duties as requested

Education and Experience:

• Associate Degree in business, finance or related field or equivalent years of relevant work experience is preferred
• Minimum of three (3) years of experience in customer service or claims experience is required
• Prior experience in managed care or other healthcare industry is preferred
• Enrollment, billing, finance, or data analysis experience is preferred

Competencies, Knowledge and Skills:

• Proficient in Microsoft Office Suite to include Word, Excel and Power Point Basic experience with ACD systems
• Basic experience with Call Management Systems
• Excellent written and verbal communication skills
• Strong interpersonal skills
• Effective problem-solving skills with attention to detail
• Effective listening and critical thinking skills
• Ability to work independently and within a team environment
• Ability to develop, prioritize and accomplish goals
• Familiarity of the healthcare field with knowledge of Medicaid and Medicare
• Ability to work in a fast-paced and constantly changing environment

Licensure and Certification:

• Current, unrestricted State Insurance License in Accident and Health within state(s) of assigned territory is/are required or ability to achieve license(s) within 30 days of hire
• Applicable Certification as required within state(s) of assigned territory or ability to achieve certification(s) within 30 days of hire and annual recertification each year thereafter is required.  For positions in states that operate under the Federally Facilitated Marketplace (FFM) and offer Marketplace plans, candidates must obtain certification from the Health Insurance Marketplace.

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time

Compensation Range:

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Organization Level Competencies

• Fostering a Collaborative Workplace Culture

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.