Medicare Advantage Appeals and Grievances Customer Experience Specialist

Blue Cross and Blue Shield of Kansas; Topeka (KS); Remote; USD 52,000 - 76,000; Full time

Benefits offered by this job

Health Insurance

Vision Insurance

Dental Insurance

Parental Leave (6 weeks)

Fertility/Adoption support

Caregiver Leave (2 weeks)

401(k) matching 5%

Tuition Reimbursement

Wellness benefits

Job summary

Blue Cross and Blue Shield of Kansas is seeking a MA Appeals and Grievances Specialist to ensure accurate processing and resolution of Medicare Advantage appeals and grievances. The role may involve handling inquiries from members, providers and representatives via telephone, email, and written correspondence.

The position supports a flexible work arrangement with remote or onsite options. Candidates residing in Kansas or Missouri or willing to relocate are encouraged to apply.

Qualifications

• High school diploma or equivalent required.
• College courses in communications and/or medical fields preferred.
• Minimum 2 years customer service experience required.
• Minimum 3 years MA or Medicaid Appeals and Grievances experience.
• Minimum 2 years MA or other call center experience advisable.
• Previous Blue Plan experience preferred.

Responsibilities

• Process MA member, member representative or provider appeals and grievances.
• Interpret MA benefit offerings and regulatory guidance to resolve issues.
• Prioritize work to meet internal and regulatory goals in a dynamic environment.
• Collaborate with internal/external contacts to resolve cases.
• Serve as backup to MA Customer Experience Representatives as needed.
• Complete special projects related to appeals, grievances or related responsibilities.

Skills

Customer service

MA Appeals

Regulatory knowledge

Call center experience

Education

High school diploma or equivalent

College courses in communications/medical fields

Job description

This job was posted by https://www.kansasworks.com : For more information, please see: https://www.kansasworks.com/jobs/13681263 Are you ready to make a difference? Choose to work for one of the most trusted companies in Kansas.

You Belong At Blue

Why Join Us?

Make a Positive Impact:

Your work will directly contribute to the health and well-being of Kansans.

Family Comes First:

Total rewards package that promotes the idea of family first for all employees. Paid vacation and sick leave with paid maternity and paternity available immediately upon hire.

Professional Growth Opportunities:

Advance your career with ongoing training and development programs.

Dynamic Work Environment:

Collaborate with a team of passionate and driven individuals in a work environment that promotes flexibility.

Trust and Stability:

Work for one of the most trusted companies in Kansas with over 80 years of commitment, compassion and community.

Inclusive Work Environment:

We pride ourselves on fostering a workplace where everyone is valued and respected.

Benefits & Perks

• Base compensation is only one component of your competitive Total

Rewards package

• Incentive pay program (EPIP)
• Health/Vision/Dental insurance
• 6 weeks paid parental leave for new mothers and fathers
• Fertility/Adoption assistance
• 2 weeks paid caregiver leave
• 401(k) plan matching up to 5%
• Tuition reimbursement
• Health & fitness benefits, discounts and resources

Job Summary

The MA Appeals and Grievances Specialist provides a world class customer service experience through processing and resolution of Medicare Advantage (MA) member, member representative, or provider appeals and grievances. May also process and resolve member, representative, provider, and other Blue Plan inquiries.

Work Location

This position is eligible to work remotely or onsite in accordance with our Telecommuting Policy. Applicants must reside in Kansas or Missouri or be willing to relocate as a condition of employment.

What you’ll do

• Process MA member, member representative or provider appeals, grievances, disputes or complaints to ensure all regulatory guidelines are met.
• Interpret, analyze, and review all MA benefit offerings and their relevant language, corporate policies, administrative and operating procedures, information systems, and regulatory guidance to address a variety of issues which may not be clear or direct.
• Manage time to optimize and prioritize work to ensure goals (internal, regulatory, etc.) are met in a fluctuating environment.
• Use discretion to make judgment calls determining appropriate sources, directions, and parameters necessary to review and resolve issues in an extremely diverse, complex, and challenging business and regulatory environment. This can include interaction with a variety of internal and/or external contacts.
• Develop effective working relationships with staff at every level within BCBSKS, other Plans, CMS Caseworkers or Account Manager, relevant suppliers and contractors, providers, and/or members and their representatives to facilitate accurate and timely resolution of cases.
• Serve as a backup to the MA Customer Experience Representatives as business needs dictate. This involves researching, resolving, and responding to inquiries and correspondence via telephone, written and email communication. Inquiries may be regarding MA benefits, eligibility, coverage and plan changes, payments, claims, prior authorizations, appeals, and grievances.
• Complete special projects related to appeals, grievances or other CXR responsibilities.

What you’ll need

Education

• High school diploma or equival nt required
• College or continuing education courses in communications and/or medical related fields preferred

Experience

• Minimum 2 years' experience customer service required
• Minimum 3 years' experience MA or Medicaid Appeals and Grievances

Required

• Minimum 2 years' experience MA or other call center or

Production-based Customer Service Experience Preferred

• Previous experience with Blue Plan preferred

Knowledge, Skills and Abilities

Ability to interact positively with internal and external customers while demonstrating empathy, adaptability, and listening skills.

Ability to listen, talk type and perform research simultaneously using various research channels.

Ability to apply excellent reasoning, analytical, and problem-solving skills, and sound judgment.

Ability to conduct extensive research, provide analyses and solutions to unusual or recurring issues, at times using discretion.

Ability to efficiently manage dissimilar issues, determine priorities and meet regulatory and/or company deadlines.

Ability to demonstrate advanced human relations skills and communi