Role Description

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.
• 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.
• Complete special projects related to appeals, grievances or other CXR responsibilities.

Qualifications

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

Requirements

• 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 communicate effectively both verbally and in writing.
• Ability to maintain strict confidentiality in handling data related to job duties.
• Ability to work collaboratively and cooperatively as a team member.
• Ability to work within a self-initiated environment with little supervision.
• Ability to achieve production-based performance goals.
• Ability to effectively use computer programs and troubleshoot simple computer issues independently or with direction.
• Ability to adhere to a rigid schedule and have regular and predictable attendance.
• Ability to obtain and maintain any departmental or legally required certifications (e.g. CMS or BCBSA requirements).
• Upon completion of training: Working knowledge of Blue Cross and Blue Shield of Kansas’ MA and other relevant systems and detailed knowledge of MA line of business and regulations governing MA appeals and grievances are required.

Compensation

$27.62 - $32.80

*Non-exempt, Grade 13*

Blue Cross and Blue Shield of Kansas offers excellent competitive compensation with the goal of retaining and growing talented team members. The compensation range for this role is a good faith estimate, it is estimated based on what a successful candidate might be paid. All offers presented to candidates are carefully reviewed to ensure fair, equitable pay by offering competitive wages that align with the individual's skills, education, experience, and training. The range may vary above or below the stated amounts.

Our Commitment to Connection and Belonging

At Blue Cross and Blue Shield of Kansas, we are committed to fostering a culture of connection and belonging, where mutual respect is at the foundation of our workplace. We provide equal employment opportunities to all individuals, regardless of race, color, religion, belief, sex, pregnancy (including childbirth, lactation, and related medical conditions), national origin, age, physical or mental disability, marital status, sexual orientation, gender identity, gender expression, genetic information (including characteristics and testing), military or veteran status, family or parental status, or any other characteristic protected by applicable law.

Blue Cross and Blue Shield of Kansas conducts pre-employment drug screening, criminal conviction check, employment verifications and education as part of a conditional offer of employment.