Appeals and Grievances Representative, Specialist - Medicare CTM

Your Role

The Medicare Sales Operations and Analysis team is responsible for Complaint Tracking Module (CTM) processing. The Appeals and Grievance, Representative, Specialist - Medicare CTM will report directly to the Manager, Sales Analysis and Operations. In this role you will address incoming CTMs per CMS SLAs, working with multiple stakeholders to identify root cause of the complaint, communicate effectively with complainant status updates and outcome of your investigation. This role will also close CTM cases in the Health Plan Management System (HPMS) with appropriate documentation, addressing all issue in complaint summary and document resolution of complaint.

Your Knowledge and Experience

• Requires a high school diploma or GED
• Requires at least 7 years combined operations experience such as Enrollment, Claims, Customer Service, Regulatory Affairs; of which at least 3 years direct experience is in Appeals/Grievances, or similar combination
• Requires proficiency in Excel
• Requires some weekend and holiday coverage
• Requires exceptional time management skills, with the ability to multitask and meet required service levels
• Requires strong analytical, problem-solving abilities, and commitment to accuracy
• Previous experience with CTM processing and related workflows desired
• Team player with a collaborative and problem-solving approach