Appeals and Grievances Specialist
A bit about us:
We’re on a mission to change healthcare — how it’s paid for, delivered, experienced. We want to put people center stage, not process or profit. We are guided by a deep belief that every person on Medicare should be treated like we would treat a member of our own family: with loving care and a profound commitment to their health and well-being.
That’s why we’re gathering a whole bunch of smart, big-hearted people to create a new kind of healthcare company — one that combines compassion, health insurance, clinical care, and technology seamlessly.
We want to throw the long ball with people we love for a cause we believe in. Life is short. Join us.
The Appeals & Grievances Specialist is responsible for ensuring professional handling of all member and provider appeals and grievances in a timely and efficient way. The Appeals & Grievances Specialist must possess broad understanding of Devoted Health products and benefits as well as regulatory requirements and timeframes. The Appeals and Grievances Specialist is responsible for the accurate coordination, efficient administration and resolution of member appeals, provider appeals and member grievances submitted by Devoted Health Plan members or providers. The role has both member outreach requirements (talking to our members to better understand and resolve their complaints) as well internal coordination, communication and training responsibilities. The Appeals & Grievances Specialist will play a key role in building trust with our members and helping Devoted improve every day.
Responsibilities will include:
- Maintain a current knowledge of Devoted Health products, policies and procedures with the ability to relate this information in a clear, concise manner to members, providers, and internal colleagues
- Manage the intake, investigation, and resolution of complaints and appeals in a timely and highly effective manner
- Correspond with the member to both meet requirements (written acknowledgement and closure letters and telephone contact and documentation as appropriate) and foster deeper trust with our members
- Complete data entry and documentation requirements in multiple systems
- Coordinate with internal departments relative to the status of a member appeal and the research needed to prepare the case for internal or external review
- Interact with Medical Directors, Clinical Guides, Legal, Member Service Guides and other areas in facilitating identification and resolution of appeals
- Identify opportunities for service improvement based on key themes in grievances and appeals
- Responsible for meeting all regulatory and department timelines
Attributes to success:
- Detail oriented - the data integrity is very important in this role and all of the documentation that goes with it
- Having at ability to meet our members where they are - in this role you'll be interacting with our members at a time the health care experience has possibly been frustrating for them
- Ability to escalate to others for support when necessary
- Time management is important in this role - getting back to our members in a timely manner is important
Desired skills and experience:
- Experience in Medicare Advantage appeals and grievances
- Bachelor’s degree or equivalent experience in health care, conflict resolution, or related field; Medicare experience required
- Superior investigation, customer service, interpersonal, and problem-solving skills
- Working knowledge of insurance products, policies, procedures, claims process.
- Ability to communicate this information to members, providers, employers, and external agencies clearly and concisely
- Strong computer, analytical, written and oral communication skills. Ability to work independently and as part of a team
If you love running towards complex challenges and transforming them into solutions, if you want to make a potentially huge impact on many lives, and if you are looking for a disruptive startup with an inspiring and talented team, Devoted Health may be the place for you!
Devoted is an equal opportunity employer. We are committed to a safe and supportive work environment in which all employees have the opportunity to participate and contribute to the success of the business. We value diversity and collaboration. Individuals are respected for their skills, experience, and unique perspectives. This commitment is embodied in Devoted’s Code of Conduct, our company values and the way we do business.
As an Equal Opportunity Employer, the Company does not discriminate on the basis of race, color, religion, sex, pregnancy status, marital status, national origin, disability, age, sexual orientation, veteran status, genetic information, gender identity, gender expression, or any other factor prohibited by law. Our management team is dedicated to this policy with respect to recruitment, hiring, placement, promotion, transfer, training, compensation, benefits, employee activities and general treatment during employment.