Grievance/Appeals Rep I Mason OH /

Company Name:
UniCare Life & Health Insurance Company
Job Description
WellPoint is one of the nations leading health benefits companies and a Fortune Top 50 company. At WellPoint, we are dedicated to improving the lives of the people we serve and the health of our communities. WellPoint strives to simplify the connection between health, care, and value for our customers.
Bring your expertise to our innovative, achievement-driven culture, and you will discover lasting rewards and the opportunity to take your career further than you can imagine.
Grievance/Appeals Representative I
Reviews, analyzes and processes claims in accordance with policies and claims events to determine the extent of the companys liability and entitlement.
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 companys liability and/or providers/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.
Triages clinical and non-clinical inquiries, grievances and appeals, prepares case files for member grievance committees/hearings.
Summarizes and presents essential information for the clinical specialist or medical director and legal counsel.
Responds to oral and written complaints sent to the Office of the Chairman, President or Vice President complaints.
Identifies barriers to customer satisfaction and recommends actions to address operational challenges.
Thoroughly documents and logs inquiry/appeal/grievance information on Grievance and Appeal Tracking systems for accurate tracking and analysis.
Good verbal and written communication, organizational and interpersonal skills.
PC proficiency.
Job Qualifications
High school diploma or equivalent required.
1 - 3 years health insurance business including customer service experience required.
Fully proficient in all areas of claims and customer service; may need guidance and supervision to complete some functions.
Medicare Part D experience preferred.
WellPoint is ranked as one of America's Most Admired Companies among health insurers by Fortune magazine, and is a 2013 DiversityInc magazine Top 50 Company for Diversity. To learn more about our company please visit us at . EOE.M/F/Disability/Veteran.
Once an offer is accepted, all external applicants are subject to a background investigation and if appropriate, drug testing. Offers of employment shall be contingent upon passing both the background investigation and drug testing (if required).
Current WellPoint associates: All referrals must be submitted through the formal associate referral process on WorkNet. Official guidelines for the associate referral program can be found in My HR.

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