Medical Appeals/Grievances Analyst

3 weeks ago

Baltimore, Maryland, United States MEDSTAR HEALTH Full time
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.
Education
  • Associate's degree required; Bachelor's degree preferred or
  • An equivalent combination of education and related experienceExperience
    • 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.
  • 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.

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