Administrative Assistant – Grievance & Appeals Department

Overview

• Provide administrative support within the Grievance & Appeals Department, ensuring compliance with regulatory standards and organizational policies.
• Perform data entry and administrative tasks, including reviewing duplicates and entering information into systems accurately.
• Assist in processing grievances, complaints, and appeals submitted by members and providers.
• Conduct investigations and research to facilitate accurate administration of benefits and clinical policies.
• Collaborate with internal and external stakeholders to ensure timely resolution of cases.
• Maintain detailed documentation of service requests and resolutions for reporting and compliance purposes.
• Support the team in clearing backlogs and meeting year-end objectives.
• Work independently and demonstrate attention to detail in a remote setting.

Key Responsibilities & Duties

• Review and classify member and provider appeals and grievances comprehensively.
• Determine eligibility, benefits, and prior activity related to claims or services in question.
• Provide written acknowledgment and responses to member and provider correspondence.
• Conduct thorough investigations and liaise with relevant departments for case resolution.
• Monitor pending reports and ensure compliance with internal and regulatory timeframes.
• Prepare cases for medical and administrative review, detailing investigation findings.
• Identify areas for improvement and provide feedback to management on quality and efficiency.
• Ensure accurate documentation and tracking of service requests and resolutions.

Job Requirements

• Associate degree in a related field required; Bachelor’s degree preferred.
• Minimum of 3 years of related professional work experience, preferably in healthcare or compliance.
• Proficiency in MS Office applications, particularly word processing and database/spreadsheet tools.
• Strong verbal and written communication skills with attention to grammatical accuracy.
• Experience in managed care or compliance environments is highly desirable.
• Ability to work independently and manage time effectively in a remote setting.
• Detail-oriented with excellent problem-solving and analytical skills.
• Customer service experience and ability to handle pressure while delivering accurate results.