Medicare Grievances Customer Service Lead Representative - Cigna Healthcare - Remote

The Grievance team manages Cigna Healthcare Medicare/ Medicaid Grievances that are presented by our member's or their representatives pertaining to the authorization of or delivery of clinical and non-clinical services.

Grievance works in collaboration with divisions within and outside the organization to resolve issues in a timely and compliant manner.

The Quality Review Coordinator is responsible for performing Internal Quality Review Audits of operational processes for Intake, Research and Resolution to ensure compliance with policies, procedures and quality standards.

The reviewer will investigate, audit, conduct root cause analysis, handle processing of determinations, track and trend findings.

The individual at this level will embody Cigna's Culture Drivers through his/her workplace behavior and will work under minimal supervision.

Duties and Responsibilities:


* Conduct quality audits of grievances, appropriate sources of information; including eligibility, claims, authorizations, service forms, faxes, and any additional information required to complete all grievance investigations.

Analyze errors and determine root causes for appropriate classification, trending, and remediation.


* Record/track quality assessment scores and provide feedback to reduce errors and improve processes and performance to ensure quality.


* Review and investigate grievance request to ensure all requests are identified, classified, and fully resolved in a compliant manner.


* Present results of investigations to senior staff and prepare written reports concerning investigation activities.


* Subsequent auditing and handling of grievance requests including processing where applicable, tracking, documenting, reporting and dispersal of findings and recommendations.


* Identify defects and improve departmental performance by supporting quality, operational efficiency and production goals.


* Assist in the development of departmental policies and procedures; reviews the efficiency of existing training.


* Meet established time frames and rates of performance for the quality and quantity of work for the position.


* Participate in regulatory and mock audit activities including universe review, universe scrubbing, risk analysis, timeliness assessment, and case walkthrough activities.


* Additional duties as assigned

Schedule:


* Mon.-Fri.

8am-5pm (Local time zone)


* Must be available to work rotating Saturdays

Candidate Qualifications


* 1+ years' experience in a Medicare, Medicaid managed care environment, customer service or grievances


* High school diploma or GED required.


* Experience in an Auditing capacity conducting root cause analysis


* Experience in clinical practice with experience in appeals & grievances, claims processing, utilization review or utilization management/case management


* Experience handling confidential information.


* Compliance & Regulatory Responsibilities: K...