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Appeals and Grievances Specialist
Network Health WI. Review assigned appeals and grievances to determine appropriate supporting documentation .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in managing appeals and grievances within health insurance, ensuring compliance with state and federal regulations while effectively communicating with members and internal departments.
Highest-signal resume keywords
Appeals And Grievance ManagementHealth Insurance ExperienceRegulatory ComplianceExcellent Communication SkillsDocumentation And Reporting
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Research RegulationsInterpret Insurance PlansCompile Supporting DocumentationResolve DiscrepanciesInvestigate And Summarize Findings
Soft Skills
Customer ServiceCollaborationEducation And Outreach
Tools & Technologies
WordExcelAppeals And Grievance Database
Industry Keywords
MedicareERISAOffice Of Commissioner Of Insurance RegulationsHealth Insurance CarrierUtilization Management
About the role
Key responsibilities & impact- Review assigned appeals and grievances to determine appropriate supporting documentation
- Compile supporting documentation for the appeal process
- Resolve discrepancies in information with internal departments or providers
- Communicate with members regarding appeal status
- Conduct outreach to gather missing information
- Educate members on the appeal or grievance process
- Investigate, summarize findings, present cases, and obtain resolutions for benefit-related cases within legally required timeframes
- Document investigations, resolutions, and member notifications in the Appeals and Grievance database
- Collaborate with the legal department regarding Administrative Law Judge hearing requests
- Prepare and submit documentation for hearings
- Represent Network Health by phone or in person to provide testimony regarding benefit determinations
- Prepare letters and written summaries for members, providers, and third parties explaining benefit determinations
- Demonstrate behavior aligned with Network Health’s philosophy, mission, values, and vision
- Perform other assigned duties
Requirements
What you’ll need- Candidates must reside in the state of Wisconsin
- Minimum of two years of experience working for a health insurance carrier or similar environment
- Experience preferably in appeals and grievance, customer service, claims, utilization management, or compliance
- Prior experience working with state and federal regulations such as Medicare, ERISA, Office of Commissioner of Insurance regulations, and similar regulations preferred
- Excellent communication skills
- Ability to interpret insurance plans and regulations
- Strong Word and Excel skills
- Ability to research regulations
- High School diploma or equivalent required
- Associates degree preferred
- Reliable internet required for home-office work
Benefits
Comp & perks- Paid to volunteer in your local neighborhood
- Eligible to work at your home office
- Reliable internet required for home-office work
- Opportunity to work hard and have fun while making a difference in local communities