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Grievance Specialist

Job Profile Summary

The Grievances Specialist is an important part of the Medicare Grievances Program, which is the heartbeat of Plan operations and a direct insight to member experience. The Grievance Specialist analyzes and investigates member complaints and works with internal and external partners to reach mitigation and resolution for the member. The Specialist will handle each grievance in accordance with organizational and regulatory guidelines.

Job Description

Primary Responsibilities

  • Conducts thorough investigations into member complaints, identifies all issues or components of the grievance, and achieves resolution through action and education to the member.
  • Researches, gathers information and evidence, and conducts timely outreach with members, providers, internal and external partners, analyzes issues, and assesses appropriate resolution.
  • Documents investigation as an accurate and complete chronological record of actions taken, communication and information obtained, and member resolution and notification for each grievance.
  • Ensures grievance resolution reflects the member’s complaint and accurately and completely addresses all components of the complaint. Keeps track of several cases simultaneously while making sure each member gets the attention they deserve in a high-volume, high-touch environment.
  • Works with departments and subject matter experts to identify potential for broader impact and appropriate corrective actions.
  • Builds and maintains good rapport and works effectively with individuals in all areas of the organization.
  • Recognizes urgent and sensitive issues/incidents and escalates to management in a timely manner to facilitate appropriate and timely response.
  • Communicates the status of assignments to Manager and team in weekly internal meetings for discussion and decision-making.
  • Demonstrates sufficient knowledge of complaint and understanding of related plan processes or functions to adequately articulate issue and resolution.
  • Proactively identifies areas of improvement for self and the department and participates in the development and completion of individual and departmental objectives and performance improvement initiatives.

Qualifications

  • Bachelors degree & 3+ years of related work experience
  • Energetic, persistent, and forward thinking with high ethical and professional standards
  • Good logical, analytical, critical thinking, and problem-solving skills
  • Ability to multi-task and operate effectively in both remote and in-person settings
  • Skilled problem-solver with the ability to take on problems and achieve a solution within a reasonable amount of time
  • Proficient investigatory skills; ability to organize, analyze, and effectively determine risk and appropriate response; ability to remain objective and separate facts from opinions
  • Firm organizational skills for prioritizing tasks to meet set deadlines
  • Effective oral and written communication skills; interpersonal skills and customer service focused; ability to interact with individuals at all levels and personalities

Working Conditions

  • While performing the duties of this job, the employee works in normal office working conditions.

Disclaimer: The job description describes the general nature and level of work being performed by people assigned to this job and is not intended to be an exhaustive list of all responsibilities, duties and skills required. The physical activities, demands, and working conditions represent those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job duties and responsibilities.


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Grievance Specialist

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