Grievance Specialist I
Grievance Specialist I
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Job Description
Join Martins Point Health Care - an innovative not-for-profit health care organization offering care and coverage to the people of Maine and beyond. As a joined force ofpeople caring for people Martins Point employees are on amission to transform our health care system while creating a healthier community. Martins Point employees enjoy an organizational culture of trust and respect where our values - taking care of ourselves and others continuous learning helping each other and having fun - are brought to life every day. Join us and find out for yourself why Martins Point has been certified as a Great Place to Work since 2015.
Position Summary
The Grievance Specialist I plays a critical role in ensuring compliance within Health Plan operations. This position receives processes investigates and resolves member inquiries and grievances for the Martins Point Health Plans as well as works across the organization to ensure the appropriate information is gathered in handling issues. Provides resolution of complaints verbally and in writing with multiple stakeholders including members providers State and/or Federal regulators and senior leadership in compliance with regulatory requirements.
Job Description
Key Outcomes
- Processes researches investigates and resolves member complaints and grievances with 100% compliance.
- Coordinates research and documentation required for oversight and monitoring of complaint and grievance cases.
- Prepares grievance documentation within contractual requirements i.e. acknowledgement letters closure letters request medical records send cases to external review and general correspondence.
- Assists in developing appropriate policies and procedures.
- Manages and monitors incoming calls and/or voicemail messages to ensure timely member response; forwards call to appropriate case owner and sends a follow up email.
- Manages data entry for tracking of incoming and outgoing grievance contact management system.
- Conducts telephone work with members providers and third-party administrators.
- Supports member educational seminars and other presentations.
- Remains current on all issues pertaining to benefits and provides expertise to members to discuss covered and non-covered benefits and financial considerations.
Education/Experience:
- Bachelors Degree or equivalent experience and education.
- 3 years of experience in managed care plan; knowledge of grievances and appeals required
Skills/Knowledge/Competencies (Behaviors):
- Demonstrates an understanding of and alignment with Martins Point Values.
- Maintains case files in organized and secure manner.
- Ability to formulate and write reports and professional correspondence.
- Strong organizational and research skills.
- Must be able to work well with all levels in the organization.
- Excellent oral and written communications skills.
- Strong analytical and problem-solving skills.
- Able to operate PC-based software programs.
- Ability to take direction/feedback.
- Provides quality customer service to internal and external customers.
There are additional competencies linked to individual contributor provider and leadership roles. Please consult with your leader to discuss additional competencies that are relevant to your position.
Terms of employment may require the applicant/incumbent to qualify obtain and maintain an ADP III Position Level of Trustworthiness from the U.S. Government Office of Personnel Management
We are an equal opportunity/affirmative action employer.
Do you have a question about careers at Martins Point Health Care Contact us at:
Required Experience:
Unclear Seniority
Employment Type
Full-Time
