Job SummaryProvides support in administration of the Appeals and Grievance process. Serves as a liaison between Members and the Plan with appeals regarding denied claims/services, referrals, membership and benefit issues and concerns regarding quality of care or service. PresentsMember appeals to the Plan Medical Staff and Center for Medicare/Medicaid Services contracted reviewer.Job DutiesPrepares and facilitates Member appeals, complaints and grievances by communicating directly with Members, their Representatives, Vendors and Medical Providers and their Representatives to obtain the necessary information to complete the appeal process successfully within the time period allowed by regulation.Investigates the full details of the appeal and complaint
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