Job Summary
Administer the Appeals and Grievance process as outlined by the Center for Medicare Services (CMS), Agency for Health Care Administration (AHCA), and the Florid Department of Financial Services (DFS); Aflac Dental & Vision, Inc.; is an administrator of vision and dental services offered by Medicare & Medicaid Advantage Plans as well as commercialized private healthcare options.
Principal Duties & Responsibilities
- Acts as a mediator between members and providers in order to provide satisfactory resolutions to complaints about services or treatment received. Each case may require thorough research and will include a documentation process to comply with state and federal applicable reporting requirements
- Responsible for notifying the member of outcome within a turnaround time defined by state regulations or the plan requirements (whichever is applicable)
- Independently reviews the members' case file to determine if representative/appellant is authorized party and if complaint is valid
- Prioritizes workflow on a consistent basis, applies key HIPAA and CMS guidelines in daily workflow, and meets turnaround times for assigned cases
- Partners with all service delivery functions (i.e. clinical, claims, billing and enrollment) to answer member questions/or works with others to resolve escalated issues
- Develops and delivers timely and professional communication dealing with complex issues at each step of the process to advise members of the progress and status of their issue
- Meets established productivity and quality standards in addition to attendance requirements
- Ensure compliance with local, state and federal laws, Medicare regulations and Aflac Dental & Vision’s policies and procedures
Education & Experience Required
- Bachelor's Degree Business Administration or related field
- Three or more years of experience in healthcare grievance and appeals administration
- Four or more years of experience in customer service in healthcare setting handling complex inquiries and requests for service
Or an equivalent combination of education and experience
Job Knowledge & Skills
- Experience in health plans, member and provider where necessary to arrive at a solution acceptable to all parties
- Strengths include organization and planning, managing multiple demands, and achieving results
- Analytical reasoning interprets and evaluates complex information, while identifying patterns and essential issues
- Word processing, spreadsheets, and database software
- Strong written and oral communication skills with particular emphasis on presentation skills
- Ability to build consensus and work effectively within a cross-departmental team
Competencies
- Acting with Integrity
- Communicating Effectively
- Pursuing Self-Development
- Serving Customers
- Supporting Change
- Supporting Organizational Goals
- Working with Diverse Populations
