Customer Service Representative

Job Description:

The Appeals and Grievance Coordinator will be responsible for managing, coordinating, and resolving member and provider complaints, grievances, and appeals, ensuring compliance with state and federal regulatory requirements. Our Appeals and Grievance Coordinator will act as the primary investigator and contact person for the member and provider and perform research, resolution, and response to complaints on behalf of a member.

Responsibilities:

· Sending appropriate acknowledgment of the grievance/appeal; educating the member or provider about the grievance/appeal process and their right to appeal to state or federal agencies (if applicable)

· Gathering all relevant information from the member or provider regarding the grievance/appeal and determining the appropriate resolution of the grievance/appeal per standard policies and procedures.

· Notifying the appropriate parties of the resolution and ensuring that all internal processes are completed to resolve the issue

· Conducts non-biased, accurate, timely, and comprehensive investigation of all the facts related to the grievance/appeal

· Thoroughly documents all action taken on behalf of the member or provider to resolve the grievance/appeal.

· Ensures that all grievances/appeals are processed in adherence to state and federal regulations