Member Services Grievance Coordinator
Bernard Nickels & Associates - Mason, OH
Apply NowJob Description
Type: ContractStart Date: ASAPEnd Date: 2/16/2025 (with potential for extension)Location: Mason, OH (HYBRID; This is mostly a WFH position, but associate will be required to assist with mail filing in the office approximately one (1) day every eight (8) weeks. Schedule: Monday-Friday, 8:00/9:00am-4:30/5:30pm (8 work hours per day)NOTE: In the future, the company may begin a rotation requiring some weekend support. If this happens, the associate will get flex time during the weekdays for the few hours of check in on the weekend.Pay Range: $17 to $20 per hourGeneral Function:The Member Services Grievance Coordinator is responsible for managing the resolution of member and provider complaints and grievances related to quality of care, access to care, and benefit determinations. The role requires collaboration with internal departments and stakeholders to ensure timely and accurate resolutions in line with regulatory and client standards.Responsibilities:Complaint/Grievance Management:Serve as the primary point of contact for resolving member and provider complaints and grievances.Conduct research, request necessary documentation (e.g., member records, claims analysis), and escalate to the Medical Director when necessary.Work with internal teams including Member Services, Claims, and Legal to resolve complex issues.Documentation and Reporting:Log, track, and process complaints and grievances using the electronic database, ensuring documentation complies with regulatory and client requirements.Prepare reports on key performance indicators (KPIs) for internal use and client reporting.Committee Coordination:Coordinate Complaint Subcommittee meetings by preparing agendas, notifying participants, and maintaining meeting minutes.Member and Provider Communication:Compose final decision letters to members and providers, reflecting the Complaint Subcommittee's decisions.Ensure decisions are implemented, and assist unsatisfied members with proper next steps.Serve as a point of contact for escalated calls, providing professional and courteous support.Dispute Resolution:Based on case analysis and historical precedents, recommend appropriate dispute resolutions.Draft formal request and response letters, summarizing case details and providing follow-up actions.Special Exception Processing:Liaise between Provider Relations and the claims department for medically necessary claims (e.g., contact lenses, low vision).Follow up with providers to obtain missing information and ensure approval/denial decisions from the Medical Director.Log and track all medically necessary claims and provide reports on their status.Process Improvement:Identify opportunities to improve current processes and procedures.Requirements:A High School Diploma/GED is required. An Associate's degree is preferred but not required.Candidates should have 2-3 years of experience in customer service, complaint resolution, or similar roles. Experience in the healthcare or vision insurance field is a plus.Customer Service/Escalation Experience: Proven experience handling customer service escalations.Strong Written Communication Skills: Ability to draft clear, professional correspondence with a focus on member and provider interactions.Desirable Attributes/Qualifications:Grievance and Appeals Experience: Direct experience managing grievances and appeals processes.Medicaid/Medicare Experience: Familiarity with handling member correspondence under Medicaid and Medicare.Managed Vision Care/Insurance Experience: Experience in the vision care or insurance industries.Performance Expectations:Meet established quality and productivity standards, including compliance with client performance guarantees and applicable federal/state regulations.
Created: 2024-10-13