Grievance Research Analyst (A7)

Position Summary: 

The Grievance Research Analyst is responsible for the timely and accurate research and resolution, within CMS guidelines, of customer complaints with added focus on root cause analysis and, when necessary, systemic and process correction recommendations. Identified resolutions will be communicated to customers verbally and/or in writing based on the method of delivery and customer request. 

*Note that this is not a Call Center position 

Responsibilities: 

• Accurately identify and document customer complaints based upon notes received from customer service, correspondence received from the customer, and/or review of the recorded customer interaction 

• Utilize knowledge of program processes and systems to research assigned grievance cases in their entirety to identify the cause of received complaints and identify a resolution appropriate to the situation 

• Convey the identified resolution to the customer or his/her representative either in writing or verbally 

• Identify and document the resolution and root cause for any assigned grievances, including accurate 

• Report identified trends in complaints and root causes to management for escalation 

• Prepare reports as requested by management. 

• Display positive demeanor, technical accuracy, and conformity to company policies. 

• Understand CMS Guidance and ensure that communication follows CMS Guidance. 

• Ensure HIPAA regulations are maintained within the immediate environment. 

• Documentation is detailed and concise as it pertains to member records. 

• Identifies the need for outbound calls for the purposes of validating information and addresses, and conducts member outreach. 

• Communicate with coworkers, management, staff, customers, and others courteously and professionally. 

• Conform with and abide by all regulations, policies, work procedures, and instructions. 

• Respond promptly when replying to correspondence and faxes. 

• Act, dress, and behave professionally to reflect a positive image of the company. 

EDUCATION AND EXPERIENCE 

• High School Diploma. An associate’s or Bachelor’s Degree is preferred   

• Three to five years’ customer service experience in a federally regulated or insurance-related field. 

• Excellent writing skills 

OTHER DUTIES AND RESPONSIBILITIES 

• Responsible for compliance with all federal, state, and local laws, rules, and regulations affecting the company. 

• Responsible for participating in quality assurance, compliance, and in-service and continuing education activities as requested by the company. 

• Responsible for performing other duties and responsibilities as required. 

Knowledge, Skills, and Abilities: 

• Excellent written, verbal, and interpersonal communication skills 

• Excellent organizational skills and attention to detail 

• Excellent documentation skills 

• Ability to provide clear and accurate information through multiple media 

• Ability to manage open requests and follow up, when necessary, without outside direction 

• Ability to effectively manage time with strong attention to detail 

• Ability to read and interpret documents, including safety rules, operating and maintenance instructions, procedure manuals and general correspondence 

• Ability to write routine reports and correspondence 

• Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals 

• Ability to carry out instructions furnished in written, oral, or diagram form 

• Ability to deal with problems involving several concrete variables in standardized situations 

• Ability to politely, tactfully, and firmly interact with a wide range of people and personalities 

• Ability to work in an environment with potential interruptions 

• Must be able to operate a computer, calculator, copier, fax machine, phone, and other office equipment