Description: Job Summary:
Responsible for reviewing all incoming cases and triaging to Case Managers and Sr. Case Managers according to regulations. Prepares initial groundwork for appeals and grievances before handing-off case. Responsible for database accuracy and ensuring compliance.

Essential Responsibilities:

Participates in managing the organizations Complaint, Grievance, and  Appeal process including: opening cases, including collection of appropriate data as directed.  Ensures that flagged cases are triaged according to timeframes. Examines specialty cases and conducts initial groundwork before sending to Case Manager. Routes cases to Case Managers across Correspondence Centers according to capacity, especially in times of backlog.
Prepares cases for audits and other state and federal governments. Ensures regulatory compliance with work product. Meets timeframes for performance while balancing the need to produce high quality work related to complex and sensitive member issues.  Ensures integrity of departmental database by thorough, timely and accurate entry and closure of cases.
Partners with and reaches out to internal staff, other MS Departments and managers to resolve issues as quickly as possible. Participates in departmental meetings, training and unit audits as requested. Escalates issues to management as appropriate to maintain compliance. Basic Qualifications: Experience

Minimum one year experience in a service related industry.
Education
High School Diploma or General Education Development (GED) required. License, Certification, Registration N/A Additional Requirements:
Strong working knowledge of federal and state laws and regulations and accreditation standards related to health care and managed care organizations.Ability to write clear, concise, grammatically correct resolution letters that meet regulatory and quality requirements.Excellent interpersonal, verbal and written communication skills.Ability to work with peers in self-managed teams to meet deadlines.Ability to use sound judgment and to handle potentially charged issues independently but with the knowledge and ability to escalate to the appropriate person / ask for help when needed.Ability to multitask and manage time in order to perform well on long term projects while being flexible enough to assimilate short term projects on an ongoing basis.Demonstrated ability to work in a time-sensitive environment.Must be able to work in a Labor/Management Partnership environment. Preferred Qualifications:
Knowledge of member grievance and appeals process preferred.Bachelors degree preferred.