<ul> <li> <p>Handles the intake processes for all Department cases that involve complex confidential issues in a highly time sensitive environment.</p> </li><li> <p>Intake of member and provider calls, faxes, email correspondence, and internal referrals; evaluation of information to determine best course of action; and follow-up with Department staff and internal departments to ensure accurate case creation are completed consistent with information relayed to members/providers and within timeframe required by law, regulation, policy, or other requirement.</p> </li><li> <p>Conduct analysis of sensitive member and provider appeals, inquiries and grievances and applies internal policies and procedures, contractual provisions, and regulatory requirements.</p> </li><li> <p>Triage cases to resolve them upon initial inquiry/intake to best service members and reduce cases escalated to Case Resolution Specialists.</p> </li><li> <p>Creates and maintains accurate electronic case files for appeals and grievances from members and providers within the scope of internal policies and procedures, and regulatory timeframe requirements.;.</p> </li><li> <p>Identifies potential issues when preparing and reviewing electronic cases including case file and program database entry and discusses these with the department supervisor or coordinator.</p> </li><li> <p>Updates electronic case folder and computer program database.</p> </li><li> <p>Handles internal and external customer service calls regarding member or provider appeals or grievance requests.</p> </li><li> <p>Is able to handle complex issues and requests by listening for understanding and communicates appropriately and professionally with internal/external customers.</p> </li><li> <p>Is able to identify what the caller is requesting, and asks questions for understanding, to offer excellent customer service experience.</p> </li><li> <p>Performs all other miscellaneous responsibilities and duties as assigned or directed.</p> </li><li> <p>Associate's degree and one year of related experience; or an equivalent combination of education and related work experience.</p> </li><li> <p>Strong verbal and written communication skills.</p> </li><li> <p>Basic working knowledge of Microsoft Office applications including Word, Excel, and Outlook.</p> </li></ul>