Appeals and Grievances Associate

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POST DATE 9/16/2016
END DATE 4/2/2018

Winston Staffing Services New York, NY

New York, NY
AJE Ref #
Job Classification
Full Time
Job Type
Company Ref #
Min Salary
Max Salary
Salary Unit
per year


This position located at a healthcare insurance company is responsible for capturing and resolving complaints, complaint appeals and grievances for members in the Medicaid and Medicare lines of business within the timeframes outlined by federal and state regulations.?Review Appeals & Grievance compliance/regulatory reports (quarterly and annual); research inconsistencies and errors, provide corrections, interface with external vendor and internal colleagues to ensure accurate reports with auditable documentation.Research complaints, complaint appeals or grievances that initiate from a variety of sources, including members, providers, state/federal regulators, and others within the timeframes outlined by federal and state regulations.?Gather comprehensive documentation from varied internal and external sources relevant to issue raised in complaint, complaint appeal or grievance. Ensure departments are responding to inquires in a timely fashion.?Prepare member correspondence, as appropriate in relationship to complaints, complaint appeals or grievances, consistent with HIPAA regulations and company protocol.?Use critical thinking to investigate and correctly categorize cases and determine a course of review action and parties to contact. Accurately identify the different types of complaints. Prepare quality of care issues for further medical review by securing medical records pertinent to the complaint, complaint appeal or grievance?Assist with the preparation of materials for


?Associates Degree or, an equivalent combination of education and relevant
work experience required. Bachelor?s Degree in Business, Health Administration
or a related field preferred.?Minimum two (2) years? of complaints and
grievances experience in a Medicare and/or Medicaid environment. Extensive
knowledge of Medicaid and Medicare regulations is preferred.?Minimum two
(2) years of claims experience; strong claims background and has worked
with claims within an insurance company/medical group. Must be fluent in
medical claims coding concepts, though certification as a coder is not
required.?Must be able to demonstrate the differences between an appeals
and grievances.?Intermediate level of proficiency with Microsoft Word and
Excel.?Demonstrate ability to work independently under time pressure.?Excellent
verbal, written and interpersonal skills are required; bilingual in English
and Spanish preferred. ?Demonstrate understanding and sensitivity to multi-cultural
values, beliefs, and attitudes of both internal and external contacts.?Demonstrate
appropriate behaviors in accordance with the organization?s vision, mission,
and valuesFor more info please email

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