Grievance & Appeals Specialist: Member Advocate

CommunityCare HMO Inc.; Tulsa (OK); On-site; USD 48,000 - 62,000; Full time

Job summary

CommunityCare HMO Inc. is seeking a dedicated professional to manage grievances and appeals for members. This role involves researching issues, preparing information for each appeal level, and ensuring timely compliance with federal, state, and accreditation regulations.

You will respond to inquiries from members and providers, document processes, and collaborate across departments to resolve issues. The position requires strong communication, organization, and attention to detail in a managed

Qualifications

• Customer service experience in managed care, insurance or healthcare environment required.
• Successful completion of Health Care Sanctions background check.
• Strong oral and written communication skills.
• Ability to work on multiple tasks.
• Proficient in Microsoft applications.
• Highly organized and attentive to detail.

Responsibilities

• Researches member issues and prepares grievance and appeals information for each level of the appeal process.
• Adheres to established grievance and appeals timeframes and ensures compliance with regulations.
• Receives and responds to member and/or provider written and oral complaints and requests.
• Interacts with Medical Management, Member Services, Claims, Pharmacy, Provider Services and Senior Management to resolve issues.
• Notifies members/providers of decisions at each level and coordinates authorization and claim payment if indicated.
• Prepares grievance and appeal files for audit and assists with CMS quarterly reports.

Skills

Customer service experience

Oral and written communication

Multitasking

Highly organized

Attention to detail

Education

High school diploma or equivalent with 5 years related experience

Associate degree with 1 year related experience

Tools

Microsoft Office

Job description

CommunityCare HMO Inc. is seeking a dedicated professional to manage grievances and appeals for members. This role involves researching issues, preparing information for each appeal level, and ensuring timely compliance with federal, state, and accreditation regulations.

You will respond to inquiries from members and providers, document processes, and collaborate across departments to resolve issues. The position requires strong communication, organization, and attention to detail in a managed