- Title: Complaints & Appeals Associate
- Code: RCI-7704-1
- Location: Newark New Jersey (NJ) 07105
- Posted Date: 01/06/2020
- Duration: 6 Months
- Name:Steve Macwan
- Email: email@example.com
- Phone: 908-704-8843 ✖
Some travel may be required between 3 Penn Plaza, Newark, NJ and 1427 Wyckoff Road, Wall, NJ
Manages resolution of complaints and appeals that have been escalated to company's executives or regulatory entities within prescribed timeframes as mandated by the regulatory entity and per designated quality standards.
This position responds directly to the member or their designated Personal Representative in matters related to Member Privacy Rights Requests. These requests are received in writing via fax or mail, or by phone through the internal Customer Service Teams. This Associate will resolve both simple and complex requests via application of the validation process. This will require applying all the necessary revisions to the systems and/or disclosing requested personal information to support and fulfill the request. Responses are issued in writing with denials requiring a detailed explanation supporting company's position. Execution of these requests must be completed accurately and thoroughly within the federally regulated timeframe. Conduct Validation process with Privacy Office to determine if company has the legal ability to disclose the requested medical information. Once the request has been validated, the investigation process is initiated based on the nature of the inquiry. The investigation process includes outreach to Legal Organizations and/or members for clarification. The process also includes the review of computer systems, reference materials and applicable legal documentation as well as the coordination of appropriate internal departments housing requesting data. End to End processing of escalated and complex cases involving members and law offices. Once the Validation and Investigation process has been completed, all relative systems are documented and updated to reflect acceptance or denial: Members Edge, NASCO, New Membership and UCSW.
- Assesses causes of complaint/appeal, conducts thorough research of issue(s), determines required course of action and final disposition.
- Candidate must have previous medical claim processing experience
- Manages resolution of complaints and/or appeals that have been escalated to executives or regulatory entities within prescribed timeframes.
- Interacts with relevant parties to facilitate timely and accurate complaint/appeals resolution.
- Authorizes claim adjustment resulting in payments at higher threshold levels.
- Contacts relevant partyies to acknowledge receipt of the complaint/appeal and uses probing techniques to clarify open issue.
- Review business team representative/vendor representative telephone calls with customers to verify accuracy of information related to complaint/appeal.
- Partners with Legal Department to review and finalize appeal determinations.
- College degree in Journalism, Communications, or related field, or equivalent in experience.
- Requires five years of business experience which must include two+ years of correspondence and/or telephone customer service experience screening, investigating and examining inquiries.
- Experience in claims processing necessary.
- Ability to navigate the various claims and service operations systems.
- Knowledge of insurance claim and membership systems preferred.
- Knowledge of medical terminology, COB, Medicare procedures preferred.
- Knowledge of UCSW preferred.
- Knowledge of Claims Policy guidelines preferred.
- Microsoft Office Suite required.
- Ability to manage and diffuse irate callers.
- Requires strong telephone/interpersonal skills, strong conflict resolution skills and the ability to remain professional during difficult interactions with customers.