Your Role
The Appeals and Grievances Pharmacy team researches and resolves member/subscriber grievances, appeals and complaints, and interprets and explains health plan benefits, policies, and procedures to appellant. The AGD - Intermediate coordinators will report to the team’s Operational Supervisor. In this role you will clarify issues, educate members in the process and interpret/explain health plan benefits, policies, procedures and functions to members and providers. You will be responsible for producing complex written correspondence to resolve member grievances, appeals and complaints.
Your Work
In this role, you will:
- Assist with telephone inquiries regarding member appeals.
- Respond to member appeals, grievances, and complaints.
- Clarify and educate members on appeals and grievance policies.
- Interpret and explain health plan benefits, policies, procedures and functions to members and providers.
- Administer ongoing grievance tracking, trending, and reporting for assigned grievances.
- Interpret and consistently perform at established Intermediate performance metrics including quality and production standards.
- Make independent decisions based on demonstrated skill proficiency and use available resources, documentation, and tools.
- Demonstrate flexibility, adaptability and support change in business needs that are made to improve team performance.
Your Knowledge and Experience
- Requires a high school diploma or GED
- Requires at least 2 years in health insurance operations such as I&M, Claims, Customer Services, Regulatory Affairs and/or Appeals/Grievances or similar combination
- General knowledge of applicable legislation/regulations and compliance
- Basic knowledge of Microsoft Office applications
Pay Range:
The pay range for this role is: $ 20.48 to $ 28.67 for California.
