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Appeals and Grievance Specialist in Scarborough, ME at KEPRO

Date Posted: 2/17/2018

Job Snapshot

  • Employee Type:
    Full-Time
  • Job Type:
    Other
  • Experience:
    Not Specified
  • Date Posted:
    2/17/2018

Job Description

KEPRO is a rapidly growing national quality improvement and care management organization. We work to ensure that over 1 billion people receive the right care, at the right time, in the right setting. KEPRO is recruiting for the following excellent career opportunity in Scarborough, ME

Appeal & Grievance Specialist

Researches, investigates and assists in resolving complaints and appeals. Documents results of the complaints and appeals and the dispositions at all levels; including notification to all required parties. Generates all acknowledgement letters and ensures they are sent out with in specified timeframe. Completes all determinations within the contractual standard timeframe. Essential functions include:

  • Ensures Triages departmental mail cases are assigned to the correct area based on the level of appeal (ex. admin appeal, retro’s, clinical, or external).
  • Generates written correspondence (acknowledgement letters) to customers such as members, providers and regulatory agencies.
  • Thoroughly documents and logs inquiry/appeal/complaint information.
  • Resolves cases in the necessary time frame in order to meet the TAT.
  • Ensures appropriate resolution to inquiries, grievances and appeals within specified time frames established by either regulatory/accreditation agencies or customer needs.

QUALIFICATIONS:

  • Requires HS Diploma or verifiable GED
  • Requires minimum 3-5 years customer service experience
  • Previous experience in the health care industry preferred
  • General knowledge of the appeals & complaints process.
  • PC proficiency to include Microsoft Office Word & Excel.
  • Excellent verbal and written communication skills.
  • Basic data entry skills.
  • Excellent Customer Service Skills.
  • Ability to meet departmental standards.
  • Must be able to review cases to be set up for the correct level of appeal.
  • Must be able to research and resolve the outcomes of complaints.

KEPRO offers challenging careers, excellent benefits and opportunities for advancement.  Come grow with a progressive health care management leader. For consideration, please submit resume and cover letter with salary requirements.  Only those candidates identified for an interview will be contacted.  No phone calls, please.  Visit us at www.kepro.com for more information on the KEPRO Family of Companies.

 

EOE AA M/F/Vet/Disability

 

KEPRO is an E-Verify employer. E-Verify is an internet based system operated by the Department of Homeland Security (DHS) in partnership with the Social Security Administration (SSA) that allows participating employers to electronically verify the employment eligibility of their newly hired employees in the United States.

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