At NationsBenefits, we are committed to helping health plan members achieve a better quality of life through supplemental benefit solutions. We are also passionate about supporting the goals of our associates and helping them do their best work. Together, we can make a meaningful and measurable difference in the lives of millions. That's something we can all be proud of.

It all begins with how we care about the people we serve. Since 2015, our mission has guided our principles toward delivering solutions for a rapidly changing industry. Compassionate Care is at the center of all we do, and it unites us to foster an environment where everyone is empowered, inspired, and equipped for success.

We offer a fulfilling work environment that attracts top talent and encourages all associates to do their part in delivering premier service to internal and external customers alike. It's how we're transforming the healthcare industry for the better. We provide career advancement opportunities within the organization with multiple locations in Florida, California, Pennsylvania, Tennessee, Texas, Utah, and India.

You might also like to know that NationsBenefits is also recognized as one of the fastest-growing companies in America. We're proud of how far we've come, and a career with us also gives you growth opportunities.

Role

As a member of The Grievance and Appeals Department, Specialists are responsible for investigating and processing grievances and appeals received by members or directly from contracted health plans. This is a challenging role with a strong impact. You will need strong analytical skills and the ability to interact with other departments effectively. Specialists work collaboratively with other internal and external functional areas and stakeholders as necessary to resolve grievances and appeals in the allocated timeframes. You will also need to effectively draft correspondence explaining the grievance and appeals resolution/outcome and the next steps/actions for the member and/or provider.

Role and Responsibilities:

• Responds to the member (customer) and client (health plan) inquiries (via phone, written, e-mail, or fax) regarding all aspects of our business in a professional, timely, accurate, and caring manner while consistently meeting all guidelines.
• Reviews, research, and directs complaints and grievances to appropriate personnel and follows up to ensure that resolution has occurred, documentation is complete, required time frames are met, and proper written communication of the decision has occurred. In most cases, prepares the written communication of the decision in plain written language for the client.
• Coordinates additional follow-up activities with appropriate department managers and/or leads and tracks to a conclusion.
• Maintains grievance and appeal case files.
• Responds to member, provider, client, and other inquiries via telephone or written correspondence while meeting all corporate guidelines and client performance standards.
• Responsible for coordination of all components of complaints/appeals, including final communication to the Client for final resolution and closure.
• Follow up to ensure complaint/appeal is handled within an established timeframe to meet company and regulatory requirements.
• Demonstrates appropriate customer-care skills such as empathy, active listening, courtesy, politeness, helpfulness, and other skills as identified.
• Records investigate and resolve member complaints.
• Assists in educating new members/providers and re-educating existing members/providers regarding health plan procedures.
• Track grievance cases by client and line(s) of business for compliance and review.
• Assist in resolving member and provider complaints.
• Behaves by company core values and expectations (initiative, accountability)
• Performs skills necessary to create a high-quality customer experience, as reflected through acceptable quality audit scores and productivity.
• Triage incomplete components of complaints to appropriate subject matter experts within the company for resolution response content to be included in the final resolution response.

Additional activities may include:

Responsible for compliance with all federal, state, and local laws, rules, and regulations affecting the Company.

Qualifications and Education Requirements:

College degree preferred

1-3 years of industry-related experience in healthcare compliance, operations, customer service, quality, or applicable experience in healthcare

1-year grievance and appeals experience preferred.

Preferred Skills:

• Strong written and verbal communication skills and an ability to work with people from diverse backgrounds.
• Grievance & Appeals, Customer Service, Training Quality assurance (3 years)
• Medicare and Health Insurance knowledge
• Ability to multi-task, good organizational, and time management skills.
• Ability to act on feedback provided by showing ownership of their development.
• Ability to read, analyzes, and interprets verbal and written instructions.
• Ability to write business correspondence.
• Ability to effectively present information and respond to questions from members.
• Ability to define problems, collects data, establish facts, and draw valid conclusions.
• Ability to work effectively within a team environment.
• Strong interpersonal and written, and verbal communication skills.
• Clear, concise, and persuasive writing and presentation skills.
• Ability to identify, analyze, and investigate potential issues.

NationsBenefits is an Equal Opportunity Employer.