Job Title: Customer Service Lead Representative
Duration: 2 Months possible extension…
Location: 100% Work from Home (WAH)
Pay : $17
Schedule & Training
Training: Monday – Friday, 8:00 AM – 5:00 PM CST
Post-Training Schedule: Flexible shifts available Monday – Friday, between 8:00 AM – 5:00 PM CST; candidates can choose their shifts after completing training
Overtime (OT): Available after training, based on performance and upon approval
Important Notes
Location Flexibility: Candidates must be able to support CST schedules and have reliable high-speed internet in a quiet, private environment.
Time Off Policy: Time off will not be granted in the first 8 weeks. Candidates with prior time-off commitments during this period will not be eligible.
Punctuality: Daily on-time attendance is required.
Performance Standards
Daily Cases: Target of closing 10 cases per day
Quality Metric: Maintain a 95% or higher audit score
DPA % (Direct Productive Activity): 75% or higher
Job Responsibilities
The Grievance Team manages grievances for Medicare/Medicaid members regarding the authorization and delivery of clinical and non-clinical services. This role requires collaboration across departments to ensure timely and compliant resolutions.
Grievance Coordination: Process Medicare customer grievances, including intake of oral or written complaints, conducting root cause analysis, creating action plans, and documenting cases within CMS guidelines.
Communication: Correspond with members, providers, and regulatory agencies to inform on case decisions and actions.
Collaboration: Work closely with Claims, Customer Service, Appeals, and Medical Management Departments.
Compliance: Adhere to all Compliance/Program Integrity requirements and HIPAA Regulations.
Professional Development: Engage in mandatory and continuing education, supporting the department and organizational goals.
Skills & Requirements
Top Skills:
Strong written communication
Critical thinking
Microsoft Office proficiency
Qualifications:
Experience: Minimum of 1 year in Appeals and Grievances (A&G) or 1+ year in Customer Service within a health insurance company.
Preferred Experience: Bilingual in Spanish.
Additional Skills: Effective verbal communication, time management, priority setting, problem-solving, and organizational skills.
Healthcare Knowledge: Familiarity with healthcare delivery systems and terminology, ideally with experience in managed care.
Caseload Management: Ability to handle high caseloads efficiently using Grievance tracking systems.
Work Setting: Previous remote work experience is preferred.
Education: High school diploma with 2 years in Medicare or Medicaid managed care, focusing on Grievances