Grievance/Appeals Rep I

Mindlance; Indianapolis (IN); On-site; USD 22,000 - 33,000; Full time

Job summary

SmartRecruiters, Inc. seeks an entry level Grievance/Appeals Rep I in Indianapolis, IN to review and process non-complex grievances and appeals from members, providers and others, following regulatory and internal guidelines.

Requires a High school diploma or GED and 3–5 years in grievances, claims, or customer service. Strong medical terminology, basic coding, and clear business writing are essential for written determinations and interdepartmental liaison.

Qualifications

• Requires a High school diploma or GED; 3 to 5 years' experience in grievances/appeals, claims, or customer service.
• Familiarity with medical coding and medical terminology.
• Understanding of provider networks and medical management/claims processes.
• Proficient business writing; able to communicate clearly in writing.

Responsibilities

• Review and process non-complex grievances and appeals per policy.
• Research claims and medical records to determine determinations.
• Prepare written communications conveying determinations.
• Coordinate with nursing/medical staff as needed.
• Serve as liaison between departments.

Skills

Medical coding basics

Medical terminology

Business writing

Provider networks understanding

Education

High school diploma or GED

Job description

One of our clients has a temporary position open for Grievance/Appeals Rep I located in Indianapolis IN with a competitive hourly rate. After reviewing your resume posted on an online job board, I believe your education and skill set could be a good fit for this particular opportunity.

Job Description

This is an entry level position in the Enterprise Grievance & Appeals Department that reviews, analyzes and processes non-complex pre service and post service grievances and appeals requests from customer types (i.e. member, provider, regulatory and third party) and multiple products (i.e. HMO, POS, PPO, EPO, CDHP, and indemnity) related to clinical and non-clinical services, quality of service, and quality of care issues to include executive and regulatory grievances.

MAJOR JOB DUTIES AND RESPONSIBILITIES: Reviews, analyzes and processes non-complex grievances and appeals in accordance with external accreditation and regulatory requirements, internal policies and claims events requiring adaptation of written response in clear, understandable language. Utilizes guidelines and review tools to conduct extensive research and analyze the grievance and appeal issue(s) and pertinent claims and medical records to either approve or summarize and route to nursing and/or medical staff for review. The grievance and appeal work is subject to applicable accreditation and regulatory standards and requirements. As such, the analyst will strictly follow department guidelines and tools to conduct their reviews. The file review components of the URAC and NCQA accreditations are must pass items to achieve the accreditation. Analyzes and renders determinations on assigned non-complex grievance and appeal issues and completion of the respective written communication documents to convey the determination. Responsibilities exclude conducting any utilization or medical management review activities which require the interpretation of clinical information. The analyst may serve as a liaison between grievances & appeals and /or medical management, legal, and/or service operations and other internal departments.

Qualifications

EDUCATION/EXPERIENCE: Requires a High school diploma or GED; 3 to 5 years' experience working in grievances and appeals, claims, or customer service, or any combination of education and/or experience which would provide an equivalent background. SKILLS: Familiarity with medical coding and medical terminology, demonstrated business writing proficiency, understanding of provider networks, the medical management process, claims process, WellPoint internal business processes, and internal local technology.