Grievance and Appeals Specialist (44016)

Job description

Job DetailsJob Location: Smithfield, RI - Smithfield, RI 02917Position Type: Full TimeEducation Level: Associates DegreeTravel Percentage: OccasionalJob Shift: DaytimeJob Category: Professional / ExperiencedThe Grievance and Appeals Specialist is responsible for handling member and provider grievances, complaints, appeals and provider claim disputes across all product lines. This role ensures compliance with contractual and regulatory requirements, including those issued by the Centers for Medicare and Medicaid Services (CMS), Executive Office of the Health and Human Services (EOHHS), Office of the Health Insurance Commissioner (OHIC), National Committee for Quality Assurance (NCQA) and other applicable standards, while meeting all turnaround times. The Specialist interprets and explains benefits, policies, and procedures to members and providers, tracks case progress, and ensures timely resolution. In addition, the Specialist will maintain accurate documentation for reporting and audits, identify trends and collaborate across departments to improve processes and member experience. Duties and Responsibilities: Responsibilities include but are not limited to: Responsible for accurat...