Medical Appeals/Grievances Analyst

4 weeks ago

Baltimore, Maryland, United States MEDSTAR HEALTH Full time

General Summary of Position

Monday - Friday, 8:30am - 5pm schedule. Position requires 1 day per week on-site (office located in Rosedale, Maryland)

Manages Maryland and District of Columbia member and provider medical appeals, Maryland complaints and grievances. Responsible for member advocate functions. Interacts directly with members, staff, physicians, and others on the telephone to resolve issues. Acts as a resource and documents all information as it relates to medical appeals/complaints and grievances. Assists with the collection of quality improvement information via telephone. Responsible for computer data input, tracking, trending, clerical, survey processing, outbound calls, and correspondence.

We recruit, retain, and advance associates with diverse backgrounds, skills, and talents equitably at all levels.

Primary Duties and Responsibilities

Correctly categorizes inquiries / complaints and refers cases appropriately to other departments for follow up; i.e. provider issues, or quality of care issues. Tracks all inquiries or complaints to ensure that cases are resolved within State required timeframes. Documents resolution and prepares and sends written correspondence in response to members initiating complaints within State / NCQA required timeframes. Assists Management with quarterly reporting when needed.Coordinates the processing of medical appeals. Evaluates, investigates, and prepares appeals by requesting / obtaining clinical information from providers via fax, mail and telephone. Must ensure that providers have submitted appeal request timely. Generates appeal acknowledgment letters per DHMH / District of Columbia regulations. Forwards appeal and related clinical information to the assigned Physician Advisor for determination.Demonstrates behavior consistent with MedStar Health mission, vision, goals, objectives and member care philosophy.Documents all pertinent clinical information in the computer system per policy. Works collaboratively with appropriate department staff, administrative and clinical personnel when appropriate. Completes denial/appeal response form and forwards to administrative staff to generate appeal letter. Ensures that appeal determination correspondence is mailed within DHMH, District of Columbia and NCQA required timeframes.Effectively conducts interviews with the members, family members or providers, and collaborates with appropriate department staff and clinical personnel when appropriate and assists the member in coordinating care or services when requested or required.Evaluates, investigates, and resolves complaints by obtaining background information and data.Processes telephone calls from providers, other department staff and members in regards to complaints, compliments, grievance procedures, denials and appeals.Responsible for ensuring all Maryland and District of Columbia clinical information related to medical appeals are scanned and attached to appropriate event in computer system.Triages all incoming appeal requests via mail, fax, etc. Responsible for forwarding all appeal requests to appropriate team members or department for timely processing.Triages provider inquiries regarding claim denials and payments, and redirects to MFC Claims Auditing Dept or MFC claims TPA to process provider inquiries.Works collaboratively with the Claims Auditor to ensure that payments by the MFC TPA are paid correctly based on fee schedules and applied business rules.

Minimum Qualifications
Education

  • Associate's degree required; Bachelor's degree preferred or
  • An equivalent combination of education and related experience

Experience

  • 1-2 years Customer service experience in a managed care or social service setting required
  • Medical appeals processing, medical billing claims auditing, and coordination of benefits experience preferred

Knowledge, Skills, and Abilities

  • Ability to type 40 words per minute.
  • Filing skills.
  • Knowledge of claims processing and medical billing.
  • Knowledge of managed care/healthcare industry preferred.
  • Ability to process complex business rules simultaneously to render decisions.
  • Attention to detail.
  • Logical reasoning and deduction skills for error and problem resolution.
  • Working knowledge of various computer software applications, including Microsoft Word and Excel and medical software.
  • Excellent verbal and written communication skills.

Why MedStar Health?
At MedStar Health, we understand that our ability to treat others well begins with how we treat each other. We work hard to foster an inclusive and positive environment where our associates feel valued, connected, and empowered. We live up to this promise through:

  • Strong emphasis on teamwork - our associates feel connected to each other and our mission as an organization. In return, our effective team environment generates positive patient outcomes and high associate satisfaction ratings that exceed the national benchmark.
  • Strategic focus on equity, inclusion, & diversity - we are committed to equity for all people and communities. We continue to build a diverse and inclusive workplace where people feel a sense of belonging and the ability to contribute to equitable care delivery and improved community health outcomes at all levels of the organization.
  • Comprehensive total rewards package - including competitive pay, generous paid time off, great health and wellness benefits, retirement savings, education assistance, and so much more.
  • More career opportunities closer to home - as the largest healthcare provider in the Baltimore-Washington, D.C. region, there are countless opportunities to grow your career and fulfill your aspirations.

About MedStar Health
MedStar Health is dedicated to providing the highest quality care for people in Maryland and the Washington, D.C., region, while advancing the practice of medicine through education, innovation, and research. Our team of 32,000 includes physicians, nurses, residents, fellows, and many other clinical and non-clinical associates working in a variety of settings across our health system, including 10 hospitals and more than 300 community-based locations, the largest home health provider in the region, and highly respected institutes dedicated to research and innovation. As the medical education and clinical partner of Georgetown University for more than 20 years, MedStar Health is dedicated not only to teaching the next generation of doctors, but also to the continuing education, professional development, and personal fulfillment of our whole team. Together, we use the best of our minds and the best of our hearts to serve our patients, those who care for them, and our communities. It's how we treat people.

MedStar Health is an Equal Opportunity (EO) Employer and assures equal opportunity for all applicants and employees. We hire people to work in different locations, and we comply with the federal, state and local laws governing each of those locations. MedStar Health makes all decisions regarding employment, including for example, hiring, transfer, promotion, compensation, benefit eligibility, discipline, and discharge without regard to any protected status, including race, color, creed, religion, national origin, citizenship status, sex, age, disability, veteran status, marital status, sexual orientation, gender identity or expression, political affiliations, or any other characteristic protected by federal, state or local EO laws. If you receive an offer of employment, it is MedStar Health's policy to hire its employees on an at-will basis, which means you or MedStar Health may terminate this relationship at any time, for any reason.

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