Consumer Affairs Advocate
November 2016 — Present
As a Consumer Affairs Advocate I receive, document, process and resolve provider, physician and/or member grievances. I serve as the primary resource to senior management, plan sponsors, enrollees, and regulatory agencies across across all states in resolution of oral and written complaints and appeals.
My Primary Responsibilities Include:
Being responsible for researching and resolving written, phone and internet complaints and complex or multi-issue appeals submitted by consumers and physicians/providers to UHG executives, state attorney generals and other regulatory agencies - including DOIs from states not under a Corrective Action Plan agreement or subject to strict regulatory scrutiny, legislators, and media.
Providing expert knowledge of the appeals process and assessing appeals status of complaints. Conducting root cause analysis by identifying potential compliance, process, or systemic breakdowns; communicating findings to management; ensuring appropriate actions are being taken for process improvement.
Assuring member complaints/grievances and appeals and provider appeals are resolved within regulatory timeframes.
Collaborating with internal departments to resolve member complaints/grievances according to regulatory timelines.
Preparing material discussed at member/provider appeal committee meetings.
Corresponding both verbally and in written format regarding member grievance and appeals and provider appeals.
Developing effective working relationships with the applicable regulatory agencies and plan personnel.
Assisting in preparation of summary grievance reports to regulatory agencies.