Grievance and Appeals Representative I
3 days ago
Miami
Job Description POSITION SUMMARY The Grievance and Appeals Representative is responsible for the intake, review, investigation, and resolution of member grievances in a managed care environment. This role ensures all grievances are handled in compliance with regulatory standards established by the Centers for Medicare & Medicaid Services (CMS) and the National Committee for Quality Assurance (NCQA), as well as internal policies and procedures. The Grievance and Appeals Representative works cross-functionally to ensure timely, accurate, and member-focused resolution of complaints while maintaining regulatory compliance and quality standards. ESSENTIAL DUTIES AND RESPONSIBILITIES To perform this job, an individual must perform each essential function satisfactorily, with or without reasonable accommodation, including, but not limited to: Key Responsibilities: • Facilitates the end-to-end handling of member grievances, including documentation, investigation, resolution, and closure within established regulatory timelines., • Conducts comprehensive research and investigation of member complaints by reviewing claims, authorizations, medical records, call logs, and correspondence., • Coordinates with internal departments (e.g., Claims, Utilization Management, Provider Relations, Customer Service) and external stakeholders to gather information and ensure accurate resolution., • Interprets and applies CMS and NCQA guidelines, as well as state and federal regulations, to determine appropriate grievance outcomes., • Ensures all grievance cases are processed within required turnaround times and meet quality and compliance standards., • Prepares clear, concise, and compliant written responses to members and/or authorized representatives, explaining the resolution and rationale., • Identifies and escalates potential quality of care issues, access concerns, or systemic trends to appropriate departments., • Maintains accurate and detailed documentation of all grievance activities in accordance with audit and regulatory requirements., • Assists in tracking, trending, and reporting grievance data to identify root causes and support quality improvement initiatives., • Participates in audits, regulatory reviews, and quality assurance activities related to grievance processing., • Communicate with members and providers via written and verbal channels to obtain additional information or provide updates as needed., • Meets departmental productivity, quality, and performance standards. QUALIFICATIONS AND EDUCATION Required Qualifications • Minimum of 2 years of experience in managed care, healthcare operations, grievances & appeals, or a related function; or equivalent combination of education and experience., • Working knowledge of CMS and NCQA regulations related to grievances and appeals., • Experience investigating and resolving member complaints, appeals, or disputes in a healthcare setting., • Familiarity with claims processing, benefits interpretation, and healthcare delivery systems., • Strong analytical, problem-solving, and investigative skills., • Excellent written and verbal communication skills, with the ability to compose professional, compliant correspondence. Preferred Qualifications • Experience in a managed care organization supporting Medicare, Medicaid, Marketplace, or other government-sponsored programs., • Knowledge of grievance classification, quality of care investigations, and regulatory reporting requirements., • Experience working with healthcare providers, medical records, and clinical documentation., • Background in customer service, call center operations, or healthcare compliance. Skills & Competencies • Regulatory Compliance (CMS/NCQA), • Critical Thinking & Investigation, • Attention to Detail, • Written Communication & Documentation, • Customer Focus & Advocacy, • Time Management & Productivity, • Collaboration & Cross-Functional Coordination WORKING CONDITIONS The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. • The noise level in the work environment is usually moderate., • Works in the field., • Interacts with patients, family members, staff, visitors, government agencies, etc., under a variety of conditions and circumstances. This work requires the following physical activities: climbing, bending, stooping, kneeling, reaching, sitting, standing, walking, lifting, finger dexterity, grasping, repetitive motions, talking, hearing and visual acuity. The work is performed indoors. Sits, stands, bends, lifts, and moves intermittently during working hours. May be sitting for a prolonged period. The work schedule is approximate, and hours/days may change based on company needs. All full-time employees are required to complete forty (40) hours per week as scheduled, including weekends and holidays as needed. May require some OT during varying seasons of the year. PHYSICAL DEMANDS The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. The employee must be able to frequently lift up to 10 pounds and occasionally lift and/or move up to 25 pounds. While performing the duties of this job, the employee is regularly required to talk or hear. The employee is frequently required to stand and walk. The employee is occasionally required to use hands to finger, handle, or feel; reach with hands and arms; climb or balance and stoop, kneel, crouch, or crawl. Specific vision abilities required for this job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus. PERFORMANCE MEASUREMENTS • Duties accomplished at the end of the day/month., • Attendance/punctuality., • Compliance with Company regulations., • Safety and Security., • Quality of work. This Job Description may be modified at any time at the discretion of the employer as business operations may deem necessary. This does not constitute an employment agreement and may not include all duties. The above statements are intended to describe the general nature and level of work being performed by individuals assigned to this position. They are not intended to be an exhaustive list of all duties, responsibilities, and skills required of personnel so classified. The incumbent must be able to work in a fast-paced environment with a demonstrated ability to juggle and prioritize multiple competing tasks and demands and to seek supervisory assistance as appropriate. Employee Acknowledgement: I have read this job description and understand what is expected of me while I occupy this role.