Grievances & Appeals Specialist
Solliciteren
Plaats
Sint-Jans-Molenbeek1080
Brussel
België
Contract
Vooltijds, Onbepaalde duurDatum gepubliceerd
2026-02-12Online to:
2026-04-13EUR 20.00 HOUR
Grievances & Appeals Specialist
- MCS Puerto Rico
- Brussel
- 23 uren geleden
GENERAL DESCRIPTION:
Analyzes, investigates, supports, and answers Grievances, Dental Pre-Service, and Payment Appeals filed by members, insureds, and Providers within the time stipulated contractually for both Lines of Business (LOB) and following the terms stated in the contracts established in MCS and the rights of Patients and Providers.
ESSENTIAL FUNCTIONS:
Analyzes, investigates, resolves, and answers Grievances, Dental Pre-Service, and Payment Appeals, filed by MCS Classicare or MCS Life policyholders, as assigned and in compliance with Centers for Medicare and Medicaid Services (CMS) regulation, Office of the Commissioner of Insurance (OCI), MCS and Grievances and Appeals Unit Policies & Procedures, others.
Consults other MCS Departments or Units and/or dental physician reviewers, as part of the analysis and investigation and/or support process, and Delegated Entities and/or suppliers.
Validates responses from MCS Departments or Units and/or dental physician reviewers, assesses the possible root cause, identifies areas of opportunity, and requires collaboration and documentation according to the impacted issue.
Documents the grievances, payment appeals, and/or dental pre-service appeals supports and analysis in the Grievances & Appeals management platform to complete the resolution or determination of the case. When required, send notifications to Net Claim system to complete the resolution.
Case reconsiderations or member requests must be handled as established per the applicable regulation and due process to CMS contracted Independent Review Entities (IRE - Maximus). Case files must be documented in English during the appeals process, considering the required documentation and timeliness. This process impacts directly, two Stars metrics related to timeliness and upheld by IRE.
For appeals, in the event a reconsideration or member request is denied and request second level appeal, for MCS Life LOB, complies with the Office of the Commissioner of Insurance (OCI) regulation and submits cases to Independent Review Organizations (IRO). Case files must be documented in English under the appeals process, considering the required documentation and timeliness.
For Grievances, records, manages, and resolves member's issues.
✓ Complies with verbal contact with the insured and/or authorized representative, or provider during the case investigation process to document and categorize the issue presented.
✓ Reviews documentation provided by operational areas to ensure proper resolution.
✓ Resolves grievances according to the timeliness established by regulation (24 hours if expedite or 30 calendar days for standard). Also consider Office of Patient Advocate (OPP) grievances management' timeframes.
✓ Investigation process includes verbal notices, written notices, RCA, if applicable, within others for proper compliance with process.
Constant monitoring of grievances and appeals timely management and procedure to avoid impact on 3 Stars metrics related to CTM, Appeals Timeliness, and Appeals Upheld.
Complies with the delivery of data required by immediate supervisor to complete reports required by Regulatory Agencies, in the established timeframes and as requested (Example: CMS, ASES, OPP, OCI, other Departments, and/or MCS Units).
Identifies providers and insureds with recurring grievances and informs immediate supervisor for referral and intervention by the appropriate department(s), e.g., Provider Department, Compliance Department, others.
Provides training on Grievances and Appeals Policies and Procedures and their impact on the Organization, in the New Employee Orientation or as required by the management team.
Collaborates, as required, in the review of Policies and participates in the definition of grievances and/or appeals processes with the Manager, Supervisor, and Unit Director.
If required, participate in MCS meetings that, due to their function, require personnel with expertise in managing Grievances and Appeals. For example, the Satisfaction Committee, Model of Care (MOC), and others.
Participates in program review and/or implementation projects, where staff with experience in managing Grievances and Appeals is required, if needed, e.g., update of PMHS, Beacon, others.
Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.
May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.
MINIMUM QUALIFICATIONS:
Education and Experience: Bachelor's degree in Business Administration, Finance, Social Sciences, or Criminal Justice. Minimum of three (3) years of experience in research, auditing, or client/provider service, preferably within the Health Insurance Industry.
OR
Education and Experience: Associate's degree in Business Administration, Finance, Social Sciences, or Criminal Justice or sixty (60) approved university credits. Minimum of five (5) years of experience in research, auditing, or client/provider service, preferably within the Health Insurance Industry.
\"Proven experience may be replaced by previously established requirements.\"
Certifications / Licenses: N/A
Other: Knowledge in Beacon and PMHS preferred.
Languages:
Spanish – Intermediate (writing, conversation, and comprehension)
English – Intermediate (writing, conversation, and comprehension)
\"MCS Healthcare Holdings, LLC. (MCS) is an Equal Employment Opportunity Employer and take Affirmative Action to recruit Protected Veterans and Individuals with Disabilities. MCS is a participating E-Verify employer.\"
Nivel de antigüedad
Intermedio
Tipo de empleo
Jornada completa
Función laboral
Otro
Sectores
Seguros
Analyzes, investigates, supports, and answers Grievances, Dental Pre-Service, and Payment Appeals filed by members, insureds, and Providers within the time stipulated contractually for both Lines of Business (LOB) and following the terms stated in the contracts established in MCS and the rights of Patients and Providers.
ESSENTIAL FUNCTIONS:
Analyzes, investigates, resolves, and answers Grievances, Dental Pre-Service, and Payment Appeals, filed by MCS Classicare or MCS Life policyholders, as assigned and in compliance with Centers for Medicare and Medicaid Services (CMS) regulation, Office of the Commissioner of Insurance (OCI), MCS and Grievances and Appeals Unit Policies & Procedures, others.
Consults other MCS Departments or Units and/or dental physician reviewers, as part of the analysis and investigation and/or support process, and Delegated Entities and/or suppliers.
Validates responses from MCS Departments or Units and/or dental physician reviewers, assesses the possible root cause, identifies areas of opportunity, and requires collaboration and documentation according to the impacted issue.
Documents the grievances, payment appeals, and/or dental pre-service appeals supports and analysis in the Grievances & Appeals management platform to complete the resolution or determination of the case. When required, send notifications to Net Claim system to complete the resolution.
Case reconsiderations or member requests must be handled as established per the applicable regulation and due process to CMS contracted Independent Review Entities (IRE - Maximus). Case files must be documented in English during the appeals process, considering the required documentation and timeliness. This process impacts directly, two Stars metrics related to timeliness and upheld by IRE.
For appeals, in the event a reconsideration or member request is denied and request second level appeal, for MCS Life LOB, complies with the Office of the Commissioner of Insurance (OCI) regulation and submits cases to Independent Review Organizations (IRO). Case files must be documented in English under the appeals process, considering the required documentation and timeliness.
For Grievances, records, manages, and resolves member's issues.
✓ Complies with verbal contact with the insured and/or authorized representative, or provider during the case investigation process to document and categorize the issue presented.
✓ Reviews documentation provided by operational areas to ensure proper resolution.
✓ Resolves grievances according to the timeliness established by regulation (24 hours if expedite or 30 calendar days for standard). Also consider Office of Patient Advocate (OPP) grievances management' timeframes.
✓ Investigation process includes verbal notices, written notices, RCA, if applicable, within others for proper compliance with process.
Constant monitoring of grievances and appeals timely management and procedure to avoid impact on 3 Stars metrics related to CTM, Appeals Timeliness, and Appeals Upheld.
Complies with the delivery of data required by immediate supervisor to complete reports required by Regulatory Agencies, in the established timeframes and as requested (Example: CMS, ASES, OPP, OCI, other Departments, and/or MCS Units).
Identifies providers and insureds with recurring grievances and informs immediate supervisor for referral and intervention by the appropriate department(s), e.g., Provider Department, Compliance Department, others.
Provides training on Grievances and Appeals Policies and Procedures and their impact on the Organization, in the New Employee Orientation or as required by the management team.
Collaborates, as required, in the review of Policies and participates in the definition of grievances and/or appeals processes with the Manager, Supervisor, and Unit Director.
If required, participate in MCS meetings that, due to their function, require personnel with expertise in managing Grievances and Appeals. For example, the Satisfaction Committee, Model of Care (MOC), and others.
Participates in program review and/or implementation projects, where staff with experience in managing Grievances and Appeals is required, if needed, e.g., update of PMHS, Beacon, others.
Must comply fully and consistently with all company policies and procedures, with local and federal laws as well as with the regulations applicable to our Industry, to maintain appropriate business and employment practices.
May carry out other duties and responsibilities as assigned, according to the requirements of education and experience contained in this document.
MINIMUM QUALIFICATIONS:
Education and Experience: Bachelor's degree in Business Administration, Finance, Social Sciences, or Criminal Justice. Minimum of three (3) years of experience in research, auditing, or client/provider service, preferably within the Health Insurance Industry.
OR
Education and Experience: Associate's degree in Business Administration, Finance, Social Sciences, or Criminal Justice or sixty (60) approved university credits. Minimum of five (5) years of experience in research, auditing, or client/provider service, preferably within the Health Insurance Industry.
\"Proven experience may be replaced by previously established requirements.\"
Certifications / Licenses: N/A
Other: Knowledge in Beacon and PMHS preferred.
Languages:
Spanish – Intermediate (writing, conversation, and comprehension)
English – Intermediate (writing, conversation, and comprehension)
\"MCS Healthcare Holdings, LLC. (MCS) is an Equal Employment Opportunity Employer and take Affirmative Action to recruit Protected Veterans and Individuals with Disabilities. MCS is a participating E-Verify employer.\"
Nivel de antigüedad
Intermedio
Tipo de empleo
Jornada completa
Función laboral
Otro
Sectores
Seguros
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