Title: Grievance/Appeals Representative I

Location: This position will work a hybrid model (remote and office). Ideal candidates will live within 50 miles of one of 6087 Technology Pkwy Columbus, GA 31820 our PulsePoint location..

The Grievance/Appeals Representative I is responsible for reviewing, analyzing and processing claims in accordance with policies and claims events to determine the extent of the company's liability and entitlement.

How you will make an impact:

• Conducts investigation and review of customer grievances and appeals involving provision of service and benefit coverage issues.

• Contacts customers to gather information and communicate disposition of case; documents interactions.

• Generates written correspondence to customers such as members, providers and regulatory agencies.

• Performs research to respond to inquiries and interprets policy provisions to determine the extent of 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.

Minimum Requirements:

• HS diploma or equivalent.

• Minimum of 1 year experience in health insurance business including customer service experience; or any combination of education and experience which would provide an equivalent background.

Preferred Qualifications:

• Good verbal and written communication, organizational, interpersonal skills and PC proficiency strongly preferred.

For URAC accredited areas, the following professional competencies apply: Associates in this role are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.