Network Research Associate
Dedale Intelligence
Job Level
Mid-LevelSenior
About the role
- Research and resolve customer grievances and complaints timely and accurately within CMS guidelines
- Perform root cause analysis and recommend systemic/process corrections when necessary
- Communicate identified resolutions to customers verbally and/or in writing per delivery method and customer request
- Accurately identify and document customer complaints from customer service notes, correspondence, or recorded interactions
- Utilize program processes and systems to research assigned grievance cases in their entirety and determine appropriate resolutions
- Identify and document resolution and root cause for assigned grievances and report trends to management for escalation
- Prepare reports as requested by management and display technical accuracy and conformity to company policies
- Ensure communications follow CMS Guidance and maintain HIPAA regulations within the immediate environment
- Ensure documentation is detailed and concise in member records
- Identify need for outbound calls to validate information and conduct member outreach
- Communicate courteously and professionally with coworkers, management, staff, customers, and others
- Conform with all regulations, policies, work procedures, and instructions; respond promptly to correspondence and faxes
- Participate in quality assurance, compliance, in-service, and continuing education activities as requested by the company
- Perform other duties and responsibilities as required
Requirements
- High School Diploma
- An associate’s or Bachelor’s Degree is preferred
- Three to five years’ customer service experience in a federally regulated or insurance-related field
- Excellent writing skills
- Excellent written, verbal, and interpersonal communication skills
- Excellent organizational skills and attention to detail
- Excellent documentation skills
- Ability to provide clear and accurate information through multiple media
- Ability to manage open requests and follow up without outside direction
- Ability to effectively manage time with strong attention to detail
- Ability to read and interpret documents, including safety rules, operating and maintenance instructions, procedure manuals and general correspondence
- Ability to write routine reports and correspondence
- Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals
- Ability to carry out instructions furnished in written, oral, or diagram form
- Ability to deal with problems involving several concrete variables in standardized situations
- Ability to politely, tactfully, and firmly interact with a wide range of people and personalities
- Ability to work in an environment with potential interruptions
- Must be able to operate a computer, calculator, copier, fax machine, phone, and other office equipment
- Understanding of CMS Guidance
- Knowledge of HIPAA regulations and ability to ensure HIPAA compliance
