Company :Highmark Inc.Job Description :
JOB SUMMARY
This job reviews inquiries to determine if they meet the definition of a grievance/appeal; documents, investigates, refers and coordinates grievances and appeals; initiates a case file for each grievance and appeal; ensures compliance with organizational and regulatory requirements for member or provider issues; independently coordinates the resolution with internal/external parties as required; and documents and summarizes to all parties involved in the case the investigation results.
ESSENTIAL RESPONSIBILITIES
- Review inquiries to determine if they meet definition of appeal/grievance.
- Request and review all related relevant documentation and assemble case file.
- Coordinate resolution results and relay investigative results with all involved parties.
- Participate in workgroup meetings to address trends in appeals and grievances and to work on process improvement initiatives with cross functional teams to reduce trends.
- May support the Quality Assurance, Appeal and other quality committees.
- Other duties as assigned or requested.
EDUCATION
Required
- High School Diploma or GED
Substitutions
- None
Preferred
- None
EXPERIENCE
Required
- 3-5 years of relevant, progressive experience in the area of specialization. Exempted experience requirements effective August 2016.
Preferred
- Experience in Customer Service or a related field
LICENSES or CERTIFICATIONS
Required
- None
Preferred
- None
SKILLS
- Knowledge of multiple processing systems and workflows
- Knowledge of claims processing methodologies
- Ability to interpret all government regulations
- Knowledge of company products
- Excellent organizational skills
- Strong verbal and written communication skills
Languages (Other than English)
None
Travel Requirement
0% - 25%
PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS
Position Type
Office-based
Teaches / trains others regularly
Occasionally
Travel regularly from the office to various work sites or from site-to-site
Occasionally
Works primarily out-of-the office selling products/services (sales employees)
Never
Physical work site required
Yes
Lifting: up to 10 pounds
Constantly
Lifting: 10 to 25 pounds
Occasionally
Lifting: 25 to 50 pounds
Occasionally
Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.
Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.
As a component of job responsibilities, employees may have access to covered information, cardholder data, or other confidential customer information that must be protected at all times. In connection with this, all employees must comply with both the Health Insurance Portability Accountability Act of 1996 (HIPAA) as described in the Notice of Privacy Practices and Privacy Policies and Procedures as well as all data security guidelines established within the Company’s Handbook of Privacy Policies and Practices and Information Security Policy.
Furthermore, it is every employee’s responsibility to comply with the company’s Code of Business Conduct. This includes but is not limited to adherence to applicable federal and state laws, rules, and regulations as well as company policies and training requirements.
Pay Range Minimum:
$21.53
Pay Range Maximum:
$32.30
Base pay is determined by a variety of factors including a candidate’s qualifications, experience, and expected contributions, as well as internal peer equity, market, and business considerations. The displayed salary range does not reflect any geographic differential Highmark may apply for certain locations based upon comparative markets.
Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities and prohibit discrimination against all individuals based on any category protected by applicable federal, state, or local law.
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For accommodation requests, please contact HR Services Online at [email protected]
California Consumer Privacy Act Employees, Contractors, and Applicants Notice
What We Do
Highmark Health, a Pittsburgh, PA based enterprise that employs more than 40,000 people who serve millions of Americans across the country, is the second largest integrated health care delivery and financing network in the nation based on revenue. Highmark Health is the parent company of Highmark Inc., Allegheny Health Network, and HM Health Solutions. Highmark Inc. and its subsidiaries and affiliates provide health insurance to nearly 5 million members in Pennsylvania, West Virginia and Delaware as well as dental insurance, vision care and related health products through a national network of diversified businesses that include United Concordia Companies, HM Insurance Group, and Visionworks. Allegheny Health Network is the parent company of an integrated delivery network that includes eight hospitals, more than 2,800 affiliated physicians, ambulatory surgery centers, an employed physician organization, home and community-based health services, a research institute, a group purchasing organization, and health and wellness pavilions in western Pennsylvania. HM Health Solutions focuses on meeting the information technology platform and other business needs of the Highmark Health enterprise as well as unaffiliated health insurance plans by providing proven business processes, expert knowledge and integrated cloud-based platforms.
A national blended health organization, Highmark Health and our leading businesses support millions of customers with products, services and solutions closely aligned to our mission of creating remarkable health experiences, freeing people to be their best.
Headquartered in Pittsburgh, we're regionally focused in Pennsylvania, Delaware, West Virginia and New York, with customers in all 50 states and the District of Columbia.
We passionately serve individual consumers and fellow businesses alike. Our companies cover a diversified spectrum of essential health-related needs, including health insurance, health care delivery, population health management, dental solutions, reinsurance solutions, and innovative technology solutions.
We’re also proud to carry forth an important legacy of compassionate care and philanthropy that began more than 170 years ago. This tradition of giving back, reinvesting and ensuring that our communities remain strong and healthy is deeply embedded in our culture, informing our decisions every day.
