Grievances And Appeals Specialist

The Grievances and Appeals Specialist is a critical function of our Compliance team. Within this role, the candidate will be responsible for ensuring the safety, integrity and trust within our platform, our members and health plans. This is a challenging role with serious impact to all stakeholders. You will need strong analytical skills and the ability to effectively interact with other departments and across multiple people. As a Member Support Specialist you will be responsible for analyzing, timely processing, documenting and resolving expressions of dissatisfactions/disputes submitted via multiple avenues. The ideal candidate will have impeccable communication skills, sound judgment, critical thinking and problem solving skills to appropriately assess risk while at the same time demonstrating compassion and empathy. The Member Support Specialist will also need to be a team player with a keen eye for detail. You will need to be able to work independently, following processes and procedures.

Essential Job Functions

• Identify any action items needed for dispute resolution while preparing written documentation for follow-up or due diligence.
• Coordinates additional follow up outreach as needed to conclude an investigation and will ensure appropriate departmental communication with managers.
• Multitasking on different research cases while operating several applications (including but not limited to) G-Suite and Microsoft excel/Google Sheets and JIRA.
• Intake and management of complex complaints from senior citizens from multiple categories including safety.
• Identify risks and escalate to proper channels in a timely manner.
• Demonstrates appropriate customer-care skills such as empathy, active listening, courtesy, politeness, helpfulness, and other skills as identified.
• Maintain a caseload of escalations (varying degrees of severity) to ensure a thorough investigation occurred, documentation is complete, and proper written communication has been finalized.
• Report and respond to investigations and information requested in a professional, timely, accurate, and caring manner while consistently meeting guidelines.
• Cross-collaboration on problems, remediation strategies, and root cause analysis.
• Other operational duties as assigned.
• Meet compliance standards for complaints, including but not limited to, monitoring internal and client-established SLAs, facilitating adequate descriptions of complaints and their factual background information, and delivering information to affected parties.
• Inbound and outbound outreach to fully investigate, analyze and document information for each case as needed.

Requirements

• College Degree preferred
• Fully bilingual in Spanish
• Strong written and verbal communication skills and an ability to work with people from diverse backgrounds displaying compassion, empathy and understanding.

Preferred Skills

• 1 year of Grievance and appeals experienced preferred
• Medicare and Health Insurance knowledge is a plus
• Non-hierarchical, with a willingness to roll-up your sleeves, multitask and dive into details.
• Self motivated, highly attentive to detail, and able to demonstrate sound judgment and critical thinking.
• 1-3 years of industry related experience in healthcare compliance, operations, customer service, quality, or applicable experience in healthcare, law enforcement and/or claims adjuster.
• Flexible work schedule to work occasional nights and weekends as/if needed.
• Proficient in Excel, Google Sheets, Zendesk and JIRA.
• Ability to analyze and work with ambiguous situations.
• Ability to work under pressure and within time constraints – excellent time management and prioritization skills are needed.
• Friendly, reliable, enthusiastic, and social personality in order to provide superior customer service.
• Comfortability making telephone calls to different parties including customers, contracted employees, or third parties such as witnesses or relevant entities such law enforcement.
• Independent and able to make decisions in the absence of direct supervision.
• Knowledge of Looker is a plus.

Papa’s culture is people first. While we have an incredible team of hard working Papa people, at the end of the day, our company is really about family and community – and we celebrate that among our employees. We encourage everyone to truly bring their whole authentic selves to work. To be transparent. To be non-hierarchical. And, above all, to be a really good person.

We see ourselves as a place where every Papa employee feels they belong, a place where careers flourish, a place that brings back purpose and joy to work, a culture where visionaries/entrepreneurs are developed.

Papa’s mission is at the core of our total rewards philosophy wherein we attract and retain high potential talent aligned with our journey. We offer gender neutral and inclusive parental leave policies that offer up to 16 weeks of 100% paid parental leave. We immensely value the benefits of a flexible workplace, while designing remote-first principles we ensured that Papa people feel psychologically safe about their career interests while being remote.

Beyond benefits: We want to take care of the whole employee and their families. To stay true to this commitment, we offer family care leave in addition to a generous paid time off policy, 401(k) match up to 4%; family forming support through access to Carrot; emotional health support tools through our medical plans such as Ginger, Happify ; access to women’s leadership network CHIEF to our senior women leaders and a host of events through a monthly culture calendar that enable emotional connectedness in a remote work environment.