Specialist, Admin Complaints, Grievances & AppealsNew$46K–$61K
The opportunity
Hi, we're Oscar. We're hiring a Specialist, Admin Complaints, Grievances & Appeals to join our CGA & MPCT team.
What you'll do
Follow established workflows to log initial assessment on complex or: escalated administrative grievances from members or providers.
Conduct, multi-faceted investigations by gathering and analyzing internal data, call logs, and correspondence.
Use workflows to reconstruct complex event timelines involving prior: authorizations, claims processing, and system-based adjudication edits to determine the cause of member or provider issues.
Collaborate with internal departments, such as Member Services, Eligibility &: Benefits, and Claims, to obtain necessary information for complete case resolution.
Based on investigative findings, determine a resolution strategy that is both: fair and compliant with company and regulatory guidelines, using established workflows.
Escalate the issue to leadership for further guidance on resolution strategy.
What they're looking for
- Draft clear, accurate, complete resolution letters, including all required regulatory elements.
- Maintain meticulous and comprehensive case files in the case management: system to provide a clear and complete audit trail for each case.
- Manage case timelines to ensure strict adherence to all federal and state mandated deadlines.
- Compliance with all applicable laws and regulations.
