Job Description
Job Title: Grievance Analyst
Position Summary:
The Grievance Analyst is responsible for the timely and accurate research and resolution, within CMS guidelines, of customer complaints with added focus on root cause analysis and, when necessary, systemic and process correction recommendations. Identified resolutions will be communicated to customers verbally and/or in writing based on the method of delivery and customer request.
Key Duties and Responsibilities:
Accurately identify and document customer complaints based upon notes received from customer service, correspondence received from the customer and/or review of the recorded customer interaction
Utilize knowledge of program processes and systems to research assigned grievance cases in their entirety to identify the cause of received complaints and identify a resolution appropriate to the situation
Convey the identified resolution to the customer or his/her representative either in writing or verbally
Identify and document the resolution and root cause for any assigned grievances including accurate
Report identified trends in complaints and root causes to management for escalation
Prepare reports as requested by management.
Display positive demeanor, technical accuracy, and conformity to company policies.
Understand CMS Guidance and ensure that communication is in accordance with CMS Guidance.
Ensure HIPAA regulations are maintained within the immediate environment.
Documentation is detailed and concise as it pertains to member records.
Identifies need for outbound calls for purposes of validating information and addresses and conducts member outreach.
Communicate with coworkers, management, staff, customers, and others in a courteous and professional manner.
Conform with and abide by all regulations, policies, work procedures and instructions.
Respond promptly when replying to correspondence and faxes.
Act, dress, and behave in a professional manner to reflect a positive image of the company.
Education and Experience:
High School Diploma. Associate's or Bachelor's Degree preferred
Three to five years' customer service experience in a federally regulated or insurance related field.
Excellent writing skills
Knowledge, Skills, and Abilities:
Excellent written, verbal, and interpersonal communication skills
Excellent organizational skills and attention to detail
Excellent documentation skills
Ability to provide clear and accurate information through multiple media
Ability to manage open requests and follow up when necessary without outside direction
Ability to effectively manage time with strong attention to detail
Ability to read and interpret documents including safety rules, operating and maintenance instructions, procedure manuals and general correspondence
Ability to write routine reports and correspondence
Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals
Ability to carry out instructions furnished in written, oral, or diagram form
Ability to deal with problems involving several concrete variables in standardized situations
Ability to politely, tactfully and firmly interact with a wide range of people and personalities
Ability to work in an environment with potential interruptions
Must be able to operate computer, calculator, copier, fax machine, phone and other office equipment
About Us
About UsConvey Health Solutions, together with Pareto Intelligence, delivers a powerful combination of purpose-built technology, advanced analytics, and expert services to help health plans thrive in a complex, post--Affordable Care Act environment.As a trusted partner to Medicare and commercial payers, we provide scalable, compliant solutions that span the entire member lifecycle--from enrollment and billing to risk adjustment, Stars performance, and member engagement. Pareto's deep analytics and financial intelligence complement Convey's operational expertise, enabling our clients to improve performance, reduce costs, and create better healthcare experiences for millions of Americans--especially seniors and vulnerable populations.Together, we help health plans scale smarter, grow stronger, and make healthcare work better for the people who need it most. Learn more at http://www.ConveyHealthSolutions.com
