Healthcare Customer Service (Grievances & Appeal)

Job Title: Customer Service Lead Representative

Duration: 2 Months possible extension...

Location: 100% Work from Home (WAH)

Pay : $17

Schedule & Training
? Training: Monday - Friday, 8:00 AM - 5:00 PM CST
? Post-Training Schedule: Flexible shifts available Monday - Friday, between 8:00 AM - 5:00 PM CST; candidates can choose their shifts after completing training
? Overtime (OT): Available after training, based on performance and upon approval

Important Notes
? Location Flexibility: Candidates must be able to support CST schedules and have reliable high-speed internet in a quiet, private environment.
? Time Off Policy: Time off will not be granted in the first 8 weeks. Candidates with prior time-off commitments during this period will not be eligible.
? Punctuality: Daily on-time attendance is required.

Performance Standards
? Daily Cases: Target of closing 10 cases per day
? Quality Metric: Maintain a 95% or higher audit score
? DPA % (Direct Productive Activity): 75% or higher

Job Responsibilities

The Grievance Team manages grievances for Medicare/Medicaid members regarding the authorization and delivery of clinical and non-clinical services. This role requires collaboration across departments to ensure timely and compliant resolutions.
? Grievance Coordination: Process Medicare customer grievances, including intake of oral or written complaints, conducting root cause analysis, creating action plans, and documenting cases within CMS guidelines.
? Communication: Correspond with members, providers, and regulatory agencies to inform on case decisions and actions.
? Collaboration: Work closely with Claims, Customer Service, Appeals, and Medical Management Departments.
? Compliance: Adhere to all Compliance/Program Integrity requirements and HIPAA Regulations.
? Professional Development: Engage in mandatory and continuing education, supporting the department and organizational goals.

Skills & Requirements

Top Skills:
? Strong written communication
? Critical thinking
? Microsoft Office proficiency

Qualifications: ? Experience: Minimum of 1 year in Appeals and Grievances (A&G) or 1+ year in Customer Service within a health insurance company. ? Preferred Experience: Bilingual in Spanish. ? Additional Skills: Effective verbal communication, time management, priority setting, problem-solving, and organizational skills. ? Healthcare Knowledge: Familiarity with healthcare delivery systems and terminology, ideally with experience in managed care. ? Caseload Management: Ability to handle high caseloads efficiently using Grievance tracking systems. ? Work Setting: Previous remote work experience is preferred. ? Education: High school diploma with 2 years in Medicare or Medicaid managed care, focusing on Grievances

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