/RESPONSIBILITIES Comprehensive knowledge in all Community First insurance products including STAR Medicaid, Children’s Health Insurance Plan (CHIP, CHIP Perinate, CHIP Perinatal, CHIP Perinatal Newborn, University Family Care Plan (UFCP),Marketplace (University Community Care Plans UCCP), Commercial, Medicare Advantage Alamo Plan HMO, Medicare D-SNP HMO to resolve member inquiries, complaints, and appeals. Specializes in Marketplace inquiries and complaints received through the Health Insurance Casework System (HICS) from Centers for Medicare & Medicaid Services (CMS), Authorities to Approve (AA), and correspondence received via member portal/website.
This also includes responding to member or regulatory agencies when appropriate and assisting with member walk-ins. Ensures all member oral or written inquiries, complaints and appeals are acknowledged, investigated and resolved ensuring timely review and resolution to member and/or regulatory agency. Able to navigate and understand third party software utilized for member eligibility and payment status EDUCATION/EXPERIENCE Bachelor’s degree in business, health care or related field with at least one year of experience in the managed care industry is required.
Minimum of four years’ experience in health insurance, or customer service industry can be substituted for education. . Complaints and appeals resolution or quality improvement management experience is also preferred