Grievance & Appeals - Grievance & Appeals Coordinator 201-1008

CommunityCare, Inc.; Tulsa (OK); Vor Ort; USD 42.000 - 65.000; Vollzeit

Zusammenfassung

CommunityCare, Inc. is seeking a Grievance and Appeals specialist to handle all written inquiries from members seeking resolution through the grievance and appeals process.

You will research member issues, prepare information for each appeal level, adhere to timeframes and regulations, and coordinate with multiple departments to ensure accurate documentation and timely decisions.

Qualifikationen

• Minimum high school diploma or equivalent with 5 years related experience OR Associates degree with 1 year related experience in customer service, member service or claims processing in an insurance environment.
• Strong written and oral communication skills; proficient in Microsoft applications.
• Managed care/insurance environment experience preferred.

Aufgaben

• Researches member issues and prepares grievance and appeals information for each level of the appeal process, adhering to timeframes and regulations.
• Receives and responds to member/provider complaints and requests with proper documentation.
• Interacts with departments and CMS to resolve issues and maintains the grievance and appeals tracking system.
• Notifies members/providers of decisions at each level and coordinates with Claims/Pharmacy to obtain authorization and process payments if indicated.
• Prepares grievance/appeal files for audit and assists with CMS quarterly reports related to Grievance and Appeals.
• Explains policies, procedures, benefits and options to members/providers related to grievance/appeals.
• Complies with Department of Insurance inquiries and documents accordingly; may involve dealing with disgruntled members.
• Performs other job-related duties as assigned.

Kenntnisse

Communication skills

Customer service

Microsoft Office

Attention to detail

Multi-tasking

Ausbildung

High school diploma or equivalent

Associates degree

Jobbeschreibung

JOB SUMMARY:

Responsible for all written inquiries from members seeking resolution through the grievance and appeals process.

KEY RESPONSIBILITIES:

• Researches member issues and prepares grievance and appeals information for each level of the appeal process. Responsible for adhering to established grievance and appeals timeframes. Assures compliance with Federal, State and Accreditation regulations.
• Receives and responds to member and/or provider written and oral complaints and requests in accordance with CommunityCare's grievance and appeals procedures. Ensures appropriate file documentation that demonstrate process steps.
• Interacts with Medical Management, Member Services, Claims, Pharmacy, Provider Services as well as Senior Management to resolve issues. Interacts with members, providers, and attorneys who represent the member regarding the grievance and appeals process. Interacts with Center for Medicare and Medicaid Services (CMS) and MAXIMUS Federal Services as indicated. Ensures the grievance and appeals electronic tracking system (GATS) is populated correctly and completely for each case. Participates in the audit process.
• Notifies members and/or providers in writing of the decision made at each level of the appeal process. Coordinates with the Claims, Pharmacy helpdesk and or Medical Management to ensure that authorization is obtained and claim payment is processed, if indicated.
• Prepares grievance and appeal files for audit. Assist Supervisor with special projects and CMS quarterly reports as it relates to Grievance and Appeals.
• Explains policies, procedures, available benefits and service options to members and/or providers related to the grievance and appeals process.
• For inquiries forwarded from the Department of Insurance, adheres to all specified communication and timeframe requirements. Documents accordingly in the file.
• Work may involve dealing with members who are disgruntled or upset.
• Perform other job-related duties as assigned.

QUALIFICATIONS:

• Customer service experience in managed care, insurance or healthcare environment required.
• Successful completion of Health Care Sanctions background check.
• Possess strong oral and written communication skills.
• Ability to work on multiple tasks.
• Proficient in Microsoft applications.
• Highly organized and attentive to detail.

EDUCATION/EXPERIENCE:

• High school diploma or equivalent PLUS 5 years related experience OR Associates degree plus 1 year of related experience required.
• Related experience consists of customer service, member service or claims processing in an insurance environment. Managed care experience preferred.