At Triple-S, we are committed to providing meaningful job experiences for Valuable People (Gente Valiosa). We strive for excellence in everything we do, from the way we work together to the way we serve our customers.
When you join Triple-S, you will be key to our efforts on delivering high-quality and affordable healthcare as well as contribute to our purpose to enable healthier lives. We serve more than 1 million consumers in Puerto Rico through our Medicare Advantage, Medicaid, Commercial, Life and Property & Casualty Businesses.
Let's build healthier communities together, join now!
JOB SUMMARY
Responsible for centralized intake, logging, and triage process (intake, classification, setup, and assignment) for all types of grievances, appeals and CTM received at the organization. Complies with the regulatory agencies’ requirements and timeframes.
ESSENTIAL FUNCTIONS
- Receives grievances and appeals filed by enrollees, providers, and regulatory agencies.
- Makes calls to enrollees and providers to validate their complaints and appeals allegations to channel them correctly, according to the regulations.
- Receives and distribute daily internal mail.
- Completes day-to-day operational tasks assigned according to defined processes and procedures.
- Completes the mailing process for all notifications of appeals and grievances processes to ensure timeliness.
- Register and classifies received cases in the system and assigns cases to the AandG Analysts and, or Coordinators.
- Prepares the grievances and appeals acknowledgement letter when applicable to comply with internal policies and regulations.
- Refers cases to operational areas to address issues presented by members, providers, and regulatory agencies.
- Receives and distribute daily fax to AG staff members and operational areas.
- Assists with maintaining regulatory compliance, timeliness requirements and ensuring accuracy standards are met.
EDUCATION
- Associate's Degree
EXPERIENCE
Associate degree (60-64 college credits) with 1 to 3 years of experience in the Health Insurance Industry, preferable. Or 3 to 5 years of experience in a Health Insurance Industry, preferable in lieu of.
LICENSES AND CERTIFICATIONS
- None required
COMPETENCIES
- Manages Ambiguity
- Instills Trust
- Collaborates
- Customer Delight
- Action Oriented
It is company policy to seek for the qualified applicants for positions throughout the company without distinction of race, color, national origin, religion, sex, gender identity, real or perceived sexual orientation, civil status, social condition, political ideologies, age, physical or mental disability, veteran status or any other characteristic protected by law. Drug-free company.
Equality Employment Opportunity/Affirmative Action for People with Disabilities/Veterans. Employer with E-Verify to verify the eligibility of employment of all the new employees.
We encourage Veterans and Disabled to Apply.