Grievances and Appeals Specialist

  • February 19, 2017
  • Triple S Salud
  • TBD
  • TBD

Job nature

Responsible for centralized intake, logging and triage process (intake, classification, setup and assignment) for all types of grievances, appeals and CTM received at the organization. Complies with the regulatory agencies requirements and timeframes.

Essential Functions

Receives complaints and appeals filed by enrollees, providers and regulatory agencies, register them in the system and in different "logs" that are required in the department. Makes calls to enrollees, providers and staff to validate their complaints and appeals allegations in order to channel them correctly, according to the regulations. Correctly classify the cases according to regulations. Creates case file with the enrollee’s eligibility information according to HEALTH SUITE/Qnex including but not limited to contract information, address, eligibility date and any other information relevant to the investigation, including interventions with the delegated entities. Also, includes in the file information of the service, claim, provider, etc. related to the case. Prepares the grievances and appeals acknowledgement letter. Assigns cases to the A&G Analysts and/or A&G Coordinators. Assist them in the investigation process by gathering the necessary information through the systems or by calling the enrollees and/or providers as necessary. Audits case files of closed complaints and appeals, reports the findings and archive the case files. Prepares daily, weekly and monthly Appeals and Grievances Reports as required by regulatory agencies and/or the Unit’s Management. Receives calls from enrollees and providers and canalize them accordingly. Coordinates training, meetings, visits, calls, send faxes and correspondence and prepare materials requisition for the Appeals and Grievances Unit. Receives and distribute daily mail and fax. Assists with maintaining regulatory compliance, timeliness requirements and ensuring accuracy standards are met. Completes day-to-day operational tasks assigned according to defined processes and procedures. Assists with tracking and maintaining case records. Assists with collecting and reporting data. Complies and is consistent with the standards, policies, and procedures of the Company, together with local and federal laws applicable to our industry, business and employment practices compliant.

Minimum Requirements

Associates Degree (60-64 college credits) with 1 to 3 years of experience in a Health Insurance Industry preferable, or 3 to 5 years of experience in a Health Insurance Industry, preferable in lieu of.

Key Competencies

All employees are expected to support actively the metrics / indicators that will facilitate the accomplishment of the corporate and departmental objectives. In any opportunity during the performance of the tasks, the employee should: Maintain the minimum professional criterion of the job, complete all required trainings, and show commitment with compliance of Company’s policies and procedures. Treat all people with respect, assuring to provide an excellent service to our policyholders, participants, providers and clients, as well as with any employee or supervisor. Maintain composure in highly stressful or adverse situations. Maintain confidential the protected information which might have access as part of the job.

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