Member Advocacy & Appeals Support Specialist II

1. Handles the intake processes for all Department cases that involve complex confidential issues in a highly time sensitive environment.

• Intake of member and provider calls, faxes, email correspondence, and internal referrals; evaluation of information to determine best course of action; and follow-up with Department staff and internal departments to ensure accurate case creation are completed consistent with information relayed to members/providers and within timeframe required by law, regulation, policy, or other requirement.
• Conduct analysis of sensitive member and provider appeals, inquiries and grievances and applies internal policies and procedures, contractual provisions, and regulatory requirements.
• Triage cases to resolve them upon initial inquiry/intake to best service members and reduce cases escalated to Case Resolution Specialists.

2. Creates and maintains accurate electronic case files for appeals and grievances from members and providers within the scope of internal policies and procedures, and regulatory timeframe requirements.

• Identifies potential issues when preparing and reviewing electronic cases including case file and program database entry and discusses these with the department supervisor or coordinator.
• Updates electronic case folder and computer program database.

3. Handles internal and external customer service calls regarding member or provider appeals or grievance requests.

• Is able to handle complex issues and requests by listening for understanding and communicates appropriately and professionally with internal/external customers.
• Is able to identify what the caller is requesting, and asks questions for understanding, to offer excellent customer service experience.

4. Performs all other miscellaneous responsibilities and duties as assigned or directed.

Qualifications

• Associate's degree and one year of related experience; or an equivalent combination of education and related work experience.
• Strong verbal and written communication skills.
• Basic working knowledge of Microsoft Office applications including Word, Excel, and Outlook.