Compliance Specialist

Job Description:

General Summary:
The Compliance Coordinator reports directly to designated Compliance Management, and is responsible for the Medicare grievance, complaint and appeals process. This position also interacts via telephone and written correspondence with Medicare members by answering questions/inquiries regarding the Medicare grievance and appeals process. Additionally this position will work closely with the Compliance Officer with regards to HPMS, HIPAA, OFAC and any other CMS and/or compliance related activities.

Primary Responsibilities:

  • Interacts with Medicare members and providers via the telephone to explain the grievance and appeals process. Correspond in writing with members and providers regarding grievance and appeals process and resolutions.
  • Record, investigate and resolve customer and provider appeals and grievances as detailed in the Grievance/Appeals procedure narrative.
  • Maintains grievance and appeals files.
  • Tracks grievances and appeals as required by CMS to ensure reporting timelines are met.
  • Assists in the education of new customers and in the re-education of existing customers to the proper appeals/grievance procedures of the health plan.
  • Tracks and follow-ups on grievance and appeals, utilizing on-line systems and procedures, according to the established guidelines.

    Required Knowledge, Skills, and Abilities:
  • Bachelor's degree or equivalent combination of education and experience.
  • Minimum 2-4 years of experience in a managed care company, preferably in a government programs (Medicare, Medicaid) product.

    Knowledge, Skills and Abilities:
  • Proficiency in MS Office Suite
  • Expertise in administering the Medicare grievance and appeals process
  • Good organizational and time management skills.

    We are proud to be an EEO/AA employer M/F/D/V. We maintain a drug-free workplace and perform pre-employment substance abuse testing.



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