Appeals & Grievances Specialist

Appeals And Grievance Specialist I

Network Health's success is rooted in its mission to create healthy and strong Wisconsin communities. It drives the decisions we make, including the people we choose to join our growing team. Network Health is seeking an Appeals And Grievance Specialist I to join our team. This individual will review appeals and grievances filed by members, investigate and summarize findings regarding the appeals, compile supporting documentation, and prepare summaries of the determination in a collaborative, innovative environment. We strive to provide world-class service to our members through the appeals process.

Job Responsibilities :

• Fully reviews all appeals and grievances assigned, to determine appropriate supporting documentation needed to address the issue being appealed.
• Compile supporting documentation for appeal process.
• Resolve any discrepancies in information with internal departments or providers as necessary.
• Communicate with members regarding status of appeals that have been submitted.
• Perform necessary outreach as appropriate to gather any missing information needed to continue with their appeal or grievance.
• Educate members on the appeal or grievance process to mitigate future potential issues or concerns which may arise.
• Investigate, summarize findings, present cases, and obtain resolution from designated sources at Network Health for all assigned benefit-related cases within legally required timeframes and in accordance with all applicable regulations.
• Accurately and consistently document all aspects of the investigation and resolution process in the Appeals And Grievance database, as well as documenting time and date verbal and written notifications were provided to members or others as required by applicable regulations and audit standards.
• Collaborate with the legal department regarding hearing requests before an Administrative Law Judge (ALJ). Prepare and submit required documentation for hearing. Represent Network Health as necessary, via phone or in person to provide testimony related to company's position on the benefit determination.
• Prepare letters or written summaries to members, providers and third parties outlining Network Health's benefit determination, clearly articulating the rationale in conformance with the member benefit document and applicable state and / or federal regulations.
• Demonstrate commitment and behavior aligned with the philosophy, mission, values and vision of Network Health.
• Other duties and responsibilities as assigned.

Other Experience And Qualifications :