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Job Title: Appeals/Grievances- NJ- Work from Home
Job Location: NY: New York
Pay Rate: -
Job Length: full time
Start Date: 2008-07-25

Company Name: The Execu|Search Group
Contact: Gregory Saukulak
Phone: email only
Fax: 212-972-0250

Description: Responsibilities for the Appeals/Grievances- NJ Work from Home include:

- Implementing, maintaining and monitoring the basic functions of the Appeals and Grievances Department
- Participating in a leadership role in the department, within company and with our providers
- Overseeing the provision of the basic Appeals and Grievances
- Entering all appeals and grievances in the Units software tracking system
- Ensuring appeals and grievances are categorized and processed within New York State and Federal timeframes
- Receiving, investigating and responding, to member appeal and grievances from all lines of business
- Identifying potential quality issues and initiating referrals to the Quality Improvement Department
- Maintaining absolute file integrity with regards to content, location and confidentiality
- Preparing for and participate in regulatory site visits
- Monitoring quality of records through monthly audits
- Developing reports necessary to monitor/ track operational efficiency and effectiveness
- Analyzing reports (both operational and analytical), and process and case outcome data to implement changes
- Implementing, monitoring and changing as necessary new operational activities and/or programs to enhance performance
- Handling ad hoc requests

Required Skills:
- 5+ years of experience in claims or Appeals and Grievance experience
- Valid NJ RN license
- Knowledge of UM / QM & case philosophies
- Knowledge of and experience with quality improvement methodologies
- Excellent decision making abilities and judgment
Job Type: HealthCare

Please refer to Job code J50437 when responding to this ad.

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