Health Plan Appeals Specialist — Grievances

AllCare Health, Inc.; Grants Pass (OR); On-site; USD 31,684 - 34,440; Full time

Benefits offered by this job

Affordable healthcare

401k retirement

Wellness programs

Flexible schedule

Job summary

AllCare Health in Grants Pass, Oregon, seeks an Appeals & Grievance Coordinator to process and resolve member and provider appeals and grievances within the Quality department.

You will investigate complex cases, coordinate with medical directors, DMAP, CMS, and independent review entities, and prepare complete case files for processing. This on-site role requires knowledge of enrollment, claims, and provider disputes.

Qualifications

• AA from a two-year college or university or 1–2 years related experience.
• Certified Professional Coder (CPC) strongly preferred.
• On-site work required for all scheduled shifts.

Responsibilities

• Investigates and resolves complex member and provider complaints related to enrollment and claims, provider payment disputes, medical appeals, and reversals.
• Provides the medical director with a complete case file for processing of the appeals and grievances and coordinates care or payment of services.
• Forwards appeals to CMS Independent Review Entity or to DMAP for further review.
• Collaborates with DMAP, CMS, or the independent review entity for review.

Education

Associate's degree (AA)

Job description

AllCare Health in Grants Pass, Oregon, seeks an Appeals & Grievance Coordinator to process and resolve member and provider appeals and grievances within the Quality department.

You will investigate complex cases, coordinate with medical directors, DMAP, CMS, and independent review entities, and prepare complete case files for processing. This on-site role requires knowledge of enrollment, claims, and provider disputes.