Med Appeals & Grievance Specialist Coordinator

Solü Technology Partners; Phoenix (AZ); On-site; USD 80,000 - 109,000; Full time

Job summary

Solü Technology Partners in Phoenix, AZ seeks a Med Appeals & Grievance Specialist Coordinator to lead clinical and administrative CMS grievance/appeal workstreams for Part C and Part D.

You will investigate member, provider and claims issues, ensure timely investigations and responses, and coordinate required CMS audits while delivering excellent service to internal and external customers.

Qualifications

• Minimum 5 years experience with CMS member services and appeals/grievances.
• Knowledge of CMS manuals and related rules for beneficiary appeals.
• Ability to interpret medical records and health plan documents for benefit determinations.
• Strong customer service orientation and interpersonal communication.

Responsibilities

• Investigate and identify member, provider, and claim-related grievance and appeal issues.
• Coordinate investigation and resolution with documentation and CMS timelines.
• Participate in CMS audits and related regulatory activities.
• Provide excellent service to internal and external customers.

Skills

CMS guidelines

Medical terminology

Keyboarding & office software

Customer service

Interpersonal skills

Education

Associate’s Degree in healthcare

Nursing Diploma

Tools

Office software

Job description

Med Appeals & Grievance Specialist Coordinator

Location Phoenix, Arizona

Category Medical

$94,432

Recognized as one of “AZ’s Most Admired Companies,” our partner is always looking for smart, passionate, and motivated individuals! You’ll have the opportunity to work with cutting-edge technologies and develop your skills, while positively impacting the future of healthcare and the community. Become part of a collaborative, purpose-driven culture today!

Employment Requirements

This opportunity is not open to C2C relationships or visa sponsorship.

This opportunity is for local candidates only.

Job Description

This position serves as a clinical and administrative subject matter expert for Part C and Part D grievance and appeal functions; investigating and identifying member, provider and/or claim processing appeals and customer service grievances issues; and ensuring that investigation, resolution and responses are processed promptly in accordance with CMS requirements and timelines.

Responsibilities

• Maintains a thorough understanding of Health Plan operations and business unit processes, work flows and system requirements, including, but not limited to, plan benefits as outlined in the Explanation of Coverage (EOC) documents, authorizations, referrals, network and non-network provider claims, and regulatory compliance.
• Maintains a current knowledge of CMS rules and regulations relating to the grievance and appeal processes.
• Participates in CMS and other audits and related activities as required.
• Coordinates investigation and resolution of complex grievance and appeal issues, reviews information provided by members, providers, and other interested parties regarding grievance and appeal cases, collects and analyzes supporting documentation, and makes the appropriate decisions involving grievance and appeal determinations.
• Performs all assigned functions according to established policies, procedures, regulatory and accreditation requirements, as well as applicable professional standards. Provides an excellent service experience to internal and external customers by consistently demonstrating our core and leadership behaviors each and every day.
• The position requires a full-time work schedule. Full-time is defined as working at least 40 hours per week, plus any additional hours as requested or as needed to meet business requirements.

Qualifications

1. Required Job Skills
   • Working knowledge of CMS Managed Care Manual Chapter 13 - Beneficiary Grievances, Organization Determinations, and Appeals and CMS Prescription Drug Benefit Manual Chapter 18 - Part D Enrollee Grievances, Coverage Determinations, and Appeals, knowledge of healthcare billing and claims adjudication processes
   • Familiarity with medical terminology, ICD, CPT, HCPCS, and DRG codes, accurate and efficient keyboarding skills, and the ability to work effectively with common office software.
2. Required Professional Competencies
   • Demonstrated ability to evaluate and interpret medical records and health plan benefit documents to make appropriate benefit determinations.
   • Must possess highly developed interpersonal skills and communications skills, with a strong customer service orientation.
3. Education: Required Work Experience
   • 5 years of work experience with CMS member services, prior authorizations, appeal and grievance, or claims functions.
4. Required Education
   • Associate’s Degree in a healthcare field of study or Nursing Diploma
5. Required Licenses
   • Licensed Practical Nurse or Registered Nurse with a current, active, unrestricted nursing license in the state of Arizona (a state in the United States).
6. Preferred Work Experience
   • 1-3 years prior work experience in a managed care environment.

*Solü Technology Partners provides equal employment opportunities (EEO) to all employees and applicants for employment without regard to race, color, religion, sex, sexual orientation, national origin, age, disability or genetics.