Incident Management Specialist IV, Grievances and Appeals

In addition to the responsibilities listed below, this position also manages the resolution of grievances and appeals cases by investigating, communicating with members and their advocates both verbally and in writing, preparing presentations of all relevant documentation to medical committees for medical service determinations and reconsiderations; identifying and partnering with appropriate entities to process escalations with an elevated level of complexity and a heightened level of resolution; reviewing cases and confirming documentation is prepared for decision making processes; leveraging an advanced knowledge of the product/service domain to negotiate satisfactory resolutions of complex customer and member grievances and appeals with appropriate groups and departments (e.g., Medical Group, Health Plan); resolving issues for members related to health care delivery, benefits, or financial barriers by collaborating with cross functional partners and leaders to resolve member challenges; independently recognizing service gaps and trends that contribute to dissatisfaction among customers, members, key stakeholders and/or functional areas; making decisions on appropriate case types using critical thinking taking into account policy and guidelines; and ensuring that all case management activities are compliant with external regulations and responses to regulators.