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KEPRO Healthcare Appeals Specialist in South Portland, Maine

Appeals and Grievance Specialist

  • Are you an experienced Appeals and Grievance Specialist looking for a new challenge?

  • Do you value care management and quality improvement?

  • Are you motivated, energetic, and excited to become part of the Kepro team?

If so, you might be our next new team member!

Who we need:

Researches, investigates and assists in resolving complaints and appeals. Documents results of the complaints and appeals and the dispositions at all levels; including notification to all required parties. Generates all acknowledgement letters and ensures they are sent out with in specified timeframe. Completes all determinations within the contractual standard timeframe.

Why us?

Kepro is a rapidly growing national quality improvement and care management organization. We work to ensure that over 20 million people receive the right care, at the right time, in the right setting.

People Focused. Mission Driven.

Shape the future of healthcare with us. We are mission driven to improve lives through healthcare quality and clinical expertise.

We do this through our people.

At Kepro, you can do meaningful work that makes a real difference for the lives of individuals across the country. We are an organization that cares deeply about our employees and we provide the training and support to do the best work of your career.

Benefits are a key component of your rewards package at Kepro. These benefits are designed to provide you and your family additional protection, security, and support for both your career and your life away from work. They are comprehensive and fit a variety of needs and situations. Our benefits include comprehensive health plans, paid time off, retirement savings, corporate wellness, educational assistance, corporate discounts and more.

What you’ll do:

Accountabilities

  • Triages departmental mail cases are assigned to the correct area based on the level of appeal (ex. admin appeal, retro, clinical, or external).

  • Generates written correspondence (acknowledgement letters) to customers such as members, providers and regulatory agencies.

  • Thoroughly documents and logs inquiry/appeal/complaint information.

  • Resolves cases in the necessary time frame in order to meet the turnaround time.

  • Ensures appropriate resolution to inquiries, grievances and appeals within specified time frames established by either regulatory/accreditation agencies or customer needs.

The list of accountabilities is not intended to be all-inclusive and may be expanded to include other duties that management may deem necessary from time to time.

What you’ll need:

Qualifications

  • Requires high school diploma or GED.

  • Associates degree from a business or secretarial school desirable.

  • Requires minimum 3-5 years customer service experience.

  • Previous experience in the health care industry preferred.

  • Excellent verbal and written communication skills.

  • Basic data entry skills.

  • Excellent customer service skills.

  • Ability to meet departmental standards.

  • Must be able to review cases to be set up for the correct level of appeal.

  • Must be able to research and resolve the outcomes of complaints.

Experience

Knowledge, Skills, Abilities

Thank You!

We know your time is valuable and we thank you in advance for applying for this position. Due to the high volume of applicants we receive, only those who are chosen to advance in our interview process will be contacted. We sincerely appreciate your interest in Kepro and invite you to apply to future openings that may be of interest. Best of luck in your search!

The Kepro Talent Acquisition Team

Mental and Physical Requirements

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations will be made as required by law in an attempt to enable an individual with a disability to perform the essential functions of this job. While performing the duties of this job, the employee is regularly required to sit for prolonged periods of time; key and/or control objects; interact extensively with internal and external customers; occasionally lift and/or move objects weighing up to 10 pounds; and occasionally travel within the state.

EOE AA M/F/Vet/Disability

Kepro is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or status as a protected veteran.

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