Appeal Resolution Manager manages the grievance process to review, investigate, document, process, negotiate, and resolve disputed medical, insurance, and other claims. Oversees work activity that is compliant with all regulatory guidelines and policy protocols. Being an Appeal Resolution Manager allocates team resources to ensure an effective and balanced case workload. Applies industry standards and uses best practices in the preparation of legal briefs. Additionally, Appeal Resolution Manager may represent the organization at hearings. Requires a bachelor's degree. Typically reports to a senior manager or head of a unit/department. The Appeal Resolution Manager manages subordinate staff in the day-to-day performance of their jobs. True first level manager. Ensures that project/department milestones/goals are met and adhering to approved budgets. Has full authority for personnel actions. To be an Appeal Resolution Manager typically requires 5 years experience in the related area as an individual contributor. 1 - 3 years supervisory experience may be required. Extensive knowledge of the function and department processes. (Copyright 2024 Salary.com)
CompanyOverview : Sunshine Enterprise is an industryleading Staffing and RecruitmentFirm. Our clients are fortune 500 companies high growth startupcompanies government and private equity firms and lead professionalservices firms.
Asa leading force in the business landscape we take pride in bringing together great people and greatorganizations by fostering a work environment that valuescreativity diversity and growth.
Ifyoure ready to embark on a rewarding career journey with a companythat prioritizes its employees explore our current jobopportunitiesbelow.
JobSummary The Grievance ResolutionSpecialist coordinates the Grievance and Appeal resolution processresponds to verbal and written Grievances and Appeals from membersand / or providers relating to member eligibility and benefitscontract administration claims processing utilization managementdecisions and pharmacy and vision decisions.
The incumbent hasfrequent external contact with members and families healthcareproviders health networks thirdparty administrators and regulators.
The incumbent collaborates with internal departments such asCustomer Service Provider Operations Pharmacy and MedicalManagement to identify factors necessary for the optimal resolutionof Grievances and Appeals.
PositionResponsibilities
Possesses the AbilityTo :
Experience &Education
PreferredQualifications
Knowledgeof :
At SunshineEnterprise USA LLC we firmly believe that our employees are theheartbeat of our organization and we are happy to offer thefollowing benefits :
Competitive pay& weekly paychecks
Health dentalvision and life insurance
401(k) savingsplan
Awards andrecognition programs
Benefiteligibility is dependent on employment status.
SUNSHINEENTERPRISE USA LLC is an Equal Opportunity Employer and does notdiscriminate on the basis of race or ethnicity religion sexnational origin age veteran disability or genetic information orany other reason prohibited by law inemployment.
Last updated : 2024-02-22
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