Provide oversight of HICS and CTM system
Ensure full resolution of HICS and CTM cases within regulatory timeframes and defined requirements
Research, follow up and resolve discrepancies associated with membership eligibility
Analyze member eligibility and take appropriate actions to resolve issues across all eligibility systems
Oversee, analyze, and provide feedback to all areas that participate in the HICS and CTM case resolution
Develop, implement, and execute HICS and CTM training to business areas as needed
Analyze and evaluate operations to identify and suggest process improvements
Monitor and track HICS and CTM data
Identify irregular trends with HICS and CTM cases; work with other areas as appropriate to identify root causes and take appropriate steps for resolution
Document and report data to appropriate internal committees
Make outbound phone calls in support of Enrollment processes
Perform any other job duties as requested

Associate Degree in business, finance or related field
Minimum of three (3) years of experience in customer service or claims experience
Prior experience in managed care or other healthcare industry is preferred
Enrollment, billing, finance, or data analysis experience is preferred
Proficient in Microsoft Office Suite to include Word, Excel, and Power Point
Basic experience with ACD systems
Basic experience with Call Management Systems
Excellent written and verbal communication skills
Strong interpersonal skills
Effective problem-solving skills with attention to detail
Ability to work independently and within a team environment
Familiarity with the healthcare field with knowledge of Medicaid and Medicare

Grievance & Appeals Resolutions Specialist III, State Insurance License in Accident and Health Required

Key skills