Medicare Advantage Grievance Specialist Remote

At Blue Cross and Blue Shield of Nebraska, we are a mission-driven organization dedicated to championing the health and well-being of our members and the communities we serve.

Our team is the power behind that promise. And, as the industry rapidly evolves and we seek ways to optimize business processes and customer experiences, thereâ??s no greater time for forward-thinking professionals like you to join us in delivering on it! As a member of Team Blue, youâ??ll find purpose, opportunities and the support you need to build a meaningful career and make a powerful impact in our community.

This role is responsible for providing support, quality reviews, coaching and training to customer service representatives assigned to the Medicare Advantage program. Focus of this position is to ensure the highest level of service and compliance with our Medicare Advantage program and to share in accountability for handling grievances and timely compliance reporting (e.g. Centers for Medicare & Medicaid Services/CMS, etc.)

This role manages the end-to-end grievance and appeals process for Medicare Advantage members, including intake, investigation, resolution, and regulatory compliance. It also involves cross-functional collaboration, reporting, committee participation, and member advocacy to ensure timely, accurate, and CMS-compliant outcomes.

Candidates applying to this remote position can live in one of the following states: Florida, Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, and Texas.

This full-time role requires a 40-hour work week with availability between 8:00 AM and 9:00 PM, Monday through Sunday, during Medicare & Medicare Advantage open season. The schedule includes rotating weekends and/or one weeknight shift, along with on-call availability approximately 1â??2 times per week.

What you'll do:

• Serve as a helpline for customer service representatives to answer questions and provide guidance on Medicare Advantage inquiries.

• Address complex customer issues and escalate, as necessary, to ensure timely resolution.

• Develop and implement training programs for customer service representatives focused on Medicare Advantage policies, procedures, and compliance requirements.

• Provide ongoing coaching and support to service representatives to enhance their knowledge and performance in handling Medicare Advantage-related inquiries.

• Monitor and evaluate customer interactions to ensure adherence to Medicare Advantage standards and regulations.

• Conduct audits and quality assessments to identify areas for improvement and implement corrective actions, as needed.

• Receive and investigate Medicare Advantage grievances from customers and internal stakeholders.

• Ensure grievances are documented, reviewed, and resolved in accordance with CMS guidelines and timelines.

• Prepare and submit reports to CMS detailing grievances and resolution actions taken.

To be considered for this position, you must have:

• Bachelorâ??s degree in healthcare administration is preferred.

• Minimum of 1-2 years of experience working in Medicare Advantage, healthcare compliance, or related area is required.

• Strong understanding of Medicare Advantage policies, regulations, and reporting requirements.

• Excellent communication and interpersonal skills, with the ability to effectively train and coach others.

• Detail-oriented with strong analytical and problem-solving abilities.

An equivalent combination of education and experience may be substituted for this requirement.

The ability to meet or exceed the attendance and timeliness requirements of their departments.

The ability to work well in a team environment and be capable of building and maintaining positive relationships with other staff, departments, and customers.

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed are representative of the knowledge, skill, and or ability required.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Other duties may be assigned.

The strongest candidates for this position will also possess:

• Proficient in Microsoft Office applications and experience with healthcare management software is a plus.

Learn more about what makes BCBSNE such an exceptional place to work by visiting NebraskaBlue.com/Careers.

We strongly believe that diversity of experience, perspective and background will lead to a better workplace for our employees and a better product for our customers and members.