• Grievance Specialist-Health Plan

    BayCare Health System (Clearwater, FL)


    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

     

    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

    **Position** Grievance Specialist-Health Plan

    **Location** Clearwater:Park Place | Business and Administrative | Full Time

    **Req ID** 117764