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Grievance/Appeals Rep I (PHL)

  • Taguig City, Alliance Global Tower
  • CLM > Claims Support
  • Full time
  • Added
  • JR20128



Responsible for reviewing, analyzing and triaging correspondence in accordance with policies and procedures. Primary duties may include, but are not limited to: Conducts investigation and review of incoming correspondence involving provision of service and benefit coverage issues. 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 company's liability and/or provider's/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. Identifies barriers to customer satisfaction and recommends actions to address operational challenges Requires K12 education (Senior HS) or equivalent and 1-2 years’ experience in health insurance business including customer service experience; or any combination of education and experience, which would provide an equivalent background. Good verbal and written communication, organizational and interpersonal skills. PC proficiency, WGS/STAR experience preferred, Previous claim or adjustment experience preferred, Familiarity with medical coding and medical terminology.

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