Summary:

This position requires the ability to work independently researching and reviewing inquiries from members, advocate for member needs, services and provide assistance in navigating the healthcare system. Also requires knowledge of benefit interpretation and claims review in order to accurately resolve and manage grievance and complaint inventories. Respond to inquiries using verbal and written forms of communication .

• Research and provide resolution to issues such as benefit denials and member grievances and complaints
• Research complex issues across multiple databases leveraging cross-functional support teams to resolve member issues and/or escalations
• Provide education and status on previously submitted pre-authorizations and pre-determination requests
• Meet the performance goals established for the position in the areas of: clear communication, issue resolution, efficiency, member satisfaction, extra effort, patience and compassion
• Comply with the quality standards such as, turnaround time, productivity and quality expectations of the department
• Ensure compliance with the Center for Medicare and Medicaid Services (CMS) guidelines is met by adhering to all state and federal regulations
• Actively communicate with other associates to guarantee accurate and timely responses to inquiries involving internal/external customer needs
• Be proactive in educating members, providers and others about CHRISTUS Health plans benefit summary
• Maintain accurate and timely responses to inquiries and generate appropriate letters to members and providers informing them of grievance and complaint decisions
• Provide recommendations and direction to both servicing providers and members in attempt to eliminate repeated complaints
• Follow the CHRISTUS Health guidelines related to Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI)
• Attend weekly and monthly team and department meetings as appropriate
• Ability to sit for long periods of time
• Ability to organize and prioritize work to meet deadlines
• Ability to work occasional long or irregular hours
• Ability to work flexible work schedule including evenings and weekends
• Good writing skills

Requirements:

• High School Diploma

Work Type:

Full Time

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About CHRISTUS Health

CHRISTUS HEALTH is an international Catholic, faith-based, not-for-profit health system comprised of almost more than 600 services and facilities, including more than 60 hospitals and long-term care facilities, 350 clinics and outpatient centers, and dozens of other health ministries and ventures. CHRISTUS operates in 6 U.S. states, Colombia, Chile and 6 states in Mexico. To support our health care ministry, CHRISTUS Health employs approximately 45,000 Associates and has more than 15,000 physicians on medical staffs who provide care and support for patients. CHRISTUS Health is listed among the top ten largest Catholic health systems in the United States.

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