What are the responsibilities and job description for the Grievance Specialist-Health Plan position at BayCare?
Why BayCare?
At BayCare, we are proud to be one of the largest employers in the Tampa Bay area. Our network consists of 16 community-based hospitals, a long-term acute care facility, home health services, outpatient centers and thousands of physicians. With the support of more than 30,000 team members, we promote a forward-thinking philosophy that’s built on a foundation of trust, dignity, respect, responsibility and clinical excellence.
Summary:
- Manages intricate grievances, collaborating closely with healthcare providers and members to resolve disagreements, and ensuring adherence to regulatory requirements.
- Conduct thorough investigations by gathering relevant information, documentation, and medical records.
- Triage, plan, and execute intake of Appeals and Grievance submissions.
- Keeping track of deadlines, ensuring all necessary documentation is completed and filed appropriately, and communicating effectively with all parties involved.
- Provide reports on the status of grievances and provide updates to management.
- Identify trends or recurring issues in member grievances and appeals and recommend process improvements to prevent future occurrences.
- Participate in internal quality assurance activities and contribute to the development of best practices for grievance and appeal resolution.
- Adhere to HIPAA requirements, guidance on documentation gathering including naming conventions and security protocols.
- Requires deep understanding of gap closure specifications.
- Knowledge of health plan operations, benefit coverage, and claims processing. Familiarity with regulatory requirements governing grievance and appeal processes, such as ERISA, HIPAA, and state-specific regulations.
- Proficiency in using computer systems and software for case management and documentation.
Minimum Qualifications:
- Required - 3 years Customer Service (or similar) within a healthcare or insurance environment with HS/GED; Or - 1 year - Customer Service (or similar) within a healthcare or insurance environment with Associates.
Facility: BayCare Health System, Admin - Non Hospital Related-BHS
Location: Park Place
Status: Full Time, Exempt: No
Shift Hours: 8:00 AM - 5:00 PM
Weekend Work: Occasional
On Call: No
How often will this team member be working remotely? Hybrid
Equal Opportunity Employer Veterans/Disabled
