Grievance & Appeals Dispute Specialist

Operations At EmblemHealth

Summary of Position

Process disputes submitted by contracted and non-contracted providers. Types of correspondence handled by the individual will include, but is not limited to; correspondence, HQSI / ESMSEF appeals and Cotiviti disputes.

Provide technical and administrative support to Grievance and Appeals dept. to ensure that departmental goals are met.

Perform administrative tasks related to the resolution and closures of grievances and appeals.

Principal Accountabilities

Intake and Preparation of Dispute Files for External Review :

• Intake disputes and compile "dispute" packets for submission to either the DRA agent or Cotiviti.
• Review new dispute receipts to confirm request is valid and to identify the appropriate dispute agent. If request is invalid, notify the provider in writing with the reasons why the request is not valid.
• Prepare disputes for external review, reviewing the previous appeal files as applicable and compiling all applicable documents to create the dispute packet.

Resolution of Disputes and Closure of Grievance and Appeals :

File Compliance :

Qualifications