Member Appeals & Grievances Specialist

Member Appeals & Grievances Specialist

Location: Birmingham, AL

Work Schedule: Hybrid schedule with regular onsite presence at the VIVA HEALTH corporate office and some work-from-home opportunities.

Why VIVA HEALTH?

VIVA HEALTH, part of the renowned University of Alabama at Birmingham (UAB) Health System, is a health maintenance organization providing quality, accessible health care. Our employees are a part of the communities they serve and proudly partner with members on their healthcare journeys.

VIVA HEALTH has been recognized by Centers for Medicare & Medicaid Services (CMS) as a high-performing health plan, receiving a 5 out of 5 Star rating - the highest rating a Medicare Advantage Plan can achieve and has been repeatedly ranked as one of the nation's Best Places to Work by Modern Healthcare.

Benefits

• Comprehensive Health, Vision, and Dental Coverage
• 401(k) Savings Plan with company match and immediate vesting
• Paid Time Off (PTO)
• 9 Paid Holidays annually plus a Floating Holiday to use as you choose
• Tuition Assistance
• Flexible Spending Accounts
• Healthcare Reimbursement Account
• Paid Parental Leave
• Community Service Time Off
• Life Insurance and Disability Coverage
• Employee Wellness Program
• Training and Development Programs to develop new skills and reach career goals
• Employee Assistance Program

See more about the benefits of working at Viva Health - https://www.vivahealth.com/careers/benefits

Job Description

The Member Appeals & Grievances Specialist will analyze and resolve all Medicare appeals and grievances received from members, non-contracted providers, and government entitles. This role will coordinate a timely resolution according to state and federal guidelines and VIVA HEALTH policies and procedures. This position will participate in an on-call rotation to process appeals and grievances on weekends and holidays.

Key Responsibilities

• Process member and non-contracted provider Medicare Part C and Part D grievances and appeals according to federal and state regulations and internal, organizational policies and procedures.
• Collaborate with internal and external subject matter experts to obtain benefit and/or clinical opinions/interpretations.
• Identify training, process improvement, and other ways to maximize plan performance and customer satisfaction.
• Act as subject matter expert regarding grievances and appeals.
• Prepare for and participate in all required audits.
• Participate in on-call rotation on weekends and holidays.

REQUIRED:

• High School Diploma or GED
• 1 - 3 years’ experience working in managed care, healthcare customer service, or appeals and grievances
• Excellent written and verbal communication skills, interpersonal skills, organization skills, and the ability to handle multiple tasks
• Ability to carefully follow processes in sequential order
• Ability to meet established productivity, schedule adherence, and quality standards
• Knowledge of computer platforms and applications of Microsoft Office
• Ability to use critical thinking skills to develop solutions to non-clinical issues using fact-based decision making
• Ability to work occasional planned and unplanned overtime to meet deadlines with minimal supervision

PREFERRED:

• Associate's Degree
• 1+ years’ experience processing Medicare appeals & grievances
• Experience working with the elderly population
• Knowledge of Medicare regulations
• Experience with administrative and/or coordinator positions with exposure to protected health information (PHI)