Appeals And Grievance Coordinator
CurrentConducts investigation and review of customer grievances and appeals involving the provision of services and benefit coverage issues, and contacts customers to gather information and communicate disposition of cases; documents interactions. Generates written correspondence to customers such as members, providers, and regulatory agencies, and performs research to respond to inquiries and interprets policy provisions to determine the extent of the company's liability and/or provider's/beneficiaries entitlement.Responds to appeals from CS Units, Provider Inquiry Units, members, providers and/or others for resolution or affirmation of previously processed claims, ensures appropriate resolution to inquiries, grievances, and appeals within specified timeframes established by either regulatory/accreditation agencies or customer needs.Identifies barriers to customer satisfaction and recommends actions to address operational challenges.