Member Advocacy & Appeals Support Specialist II
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Description
- 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.
- 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.
- 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.
- Performs all other miscellaneous responsibilities and duties as assigned or directed.