Voice & Non-Voice Call Center Agent

1. Customers submit their appeal or complaint pertaining to authorizations, claims, benefits, eligibility. These disputes come to Complaint and Appeal Analyst

2. The complaint and appeal analyst reviews the member’s dispute and data key elements. The analyst needs to comprehend the dispute, decide if the original claim was processed correctly using specific policies/state mandates/member benefits /authorizations/member’s eligibility

3. If any additional information is needed to carry out the review, an outbound Call to be made to Member/Provider – Preferred

4. If original claim decision was incorrect corresponding claims must be sent for reprocessing/rework

5. If the claim decision was correct, then analyst updates relevant systems with decision and responds to the member in writing within the specified Turn Around Time