Under the general direction of the Appeals and Grievances Supervisor, the Specialist is responsible for ensuring professional handling of all member and provider appeals and grievances in a timely and efficient way. The Specialist must possess broad understanding of all THP/THPMP products and benefits as well as have an understanding of regulatory requirements and timeframes. Specialists routinely interact with members, providers and other internal and external constituents about highly escalated issues.
Essential functions will occur simultaneously; therefore, the employee must be able to appropriately handle each of these functions, prioritize them, and seek assistance when necessary. These essential functions need to be performed on a consistent and regular basis, using good judgment. The employee must have the ability to learn and apply Tufts Health Plan policies and complex and frequently changing regulatory requirements consistently and the judgment to seek out guidance as needed. The Specialist is responsible for the accurate coordination, efficient administration and resolution of member appeals, provider appeals and member grievances submitted by Tufts Health Plan members (member appeals and grievances) or providers (provider appeals) for all products.
The Specialist may work on all of these processes dependent on department workload and work distribution, although typically is assigned a particular function
EDUCATION: (Minimum education & certifications required)
A Bachelor's Degree is preferred in health care management, business, or related field (equivalent experience may be considered).
EXPERIENCE: (Years of experience)
Two to three years of office experience with emphasis in customer service required.
Effective interpersonal/communication skills are essential.
Knowledge of basic medical terminology a plus.
SKILL REQUIREMENTS: (Include interpersonal skills)
Demonstrated proficiency in operating a personal computer and related equipment including knowledge and demonstrated ability in the use of Windows applications and other comparable systems/applications.
Must possess initiative, balanced judgment, objectivity and the ability to independently plan and prioritize one's own work to assure maximum efficiency.
Must be able to organize, plan and implement the functions of
Member Appeals and Grievances and Provider Appeals, maintain timelines and turnaround times to meet multiple requirements/regulations established by external regulating bodies and applicable state and federal laws
Demonstrated ability to synthesize and process complex information and deliver the information, both verbally and written, in a clear, concise, and articulate manner.
Requires strong verbal and written skills to effectively communicate at both detail and summary levels to a variety of constituents.
Requires excellent interpersonal skills in order to communicate and work with multiple constituents.
Must be able to exercise patience and high level of diplomacy to recognize politically sensitive issues.