Appeals & Grievances Coordinator

3 weeks ago


Salt Lake City, United States American Health Partners Full time

You must reside in one of the following states for this position:

AL, AR, AZ, FL, GA, IA, ID, IL, IN, KS, KY, LA MI, MO, MS, NC, NY, OH, OK, PA, SC, TN, TX, UT, WI

American Health Plans, a division of Franklin, Tennessee-based American Health Partners Inc. owns and operates Institutional Special Needs Plans (I-SNPs) for seniors who reside in long-term care facilities. In partnership with nursing home operators, these Medicare Advantage plans manage medical risk by improving patient care to reduce emergency room visits and avoidable hospitalizations. This division currently operates in Tennessee, Georgia, Missouri, Kansas, Oklahoma, Utah, Texas, Mississippi, Iowa, Idaho, Louisiana, and Indiana with planned expansion into other states in 2025. For more information, visit AmHealthPlans.com.

If you would like to be part of a collaborative, supportive and caring team, we look forward to receiving your application

Benefits and Perks include:

* Affordable Medical/Dental/Vision insurance options
* Generous paid time-off program and paid holidays for full time staff
* TeleDoc 24/7/365 access to doctors
* Optional short- and long-term disability plans
* Employee Assistance Plan (EAP)
* 401K retirement accounts with company match
* Employee Referral Bonus Program

Position Summary:

The purpose of this position is to process, track and follow up on all medical necessity and administrative denials and appeals for Medicare Advantage members in accordance with Medicare guidelines and regulations. The Grievances and Appeals Coordinator is a critical team player who works in a fast-paced, ever-changing environment with a passionate team and must deliver daily.

Essential Functions: To perform this job, an individual must perform each essential function satisfactorily with or without a reasonable accommodation.

* Capture, investigate and respond to all complaints regarding customer grievances and appeals involving provision of service and benefit coverage issues
* Conduct pertinent research to evaluate, answer, and close appeals
* Ensure appropriate resolution to inquiries, grievances and appeals within specified timeframes established by either regulatory/accreditation agencies or customer needs; ensure appropriateness of the response in compliance with State and Federal guidelines
* Assist members when filing appeals; educate member, document and route the information appropriately
* Prepare response letters, notifications, and acknowledgements for members and provider complaints, grievances and appeals
* Maintain grievance information and supporting documentation in accordance with all state, federal, NCQA, URAC and other regulatory agency standards / regulations
* Escalate issues appropriately or work with other departments to resolve member issues
* Ensure all HIPAA and State requirements/regulations are always adhered to
* Identify issues and root causes of appeals and disputes for plan management and compliance
* Identify and report trends and/or areas of opportunities to supervisor
* Maintain and update appeal and grievance policies and procedures, member correspondence materials, and process manuals
* Perform internal audits of grievance and appeals process
* Maintain privacy and confidentiality of records, conditions, and other information relating to residents, employees and facility
* Encourage an atmosphere of optimism, warmth and interest in patients' personal and health care needs
* Meet critical time frames on a frequent and regular basis

Required Skills:

* Excellent communication skills and active listening
* Positive, engaging customer service skills
* Meet critical time frames on a frequent and regular basis
* Work cooperatively with internal departments and external stakeholders
* Perform in potentially stressful situations, such as state, federal, NCQA, URAC or other regulatory/accrediting agency audits

Required Work Experience:

* Minimum (3) three years' health plan experience; insurance, compliance, managed care, or quality assurance preferred
* Grievance and appeals experience preferred, specifically within a Medicare and/or Medicare Advantage context
* Experience working with physicians and clinicians in the appeals and grievance space, preferred
* Knowledge and understanding of complaint and appeal procedures
* Knowledge of managed care, particularly utilization management processes
* Knowledge of NCQA, HEDIS or general accreditation requirements and guidelines for utilization management, denials and appeals
* Familiarity with Appeals processes and regulatory requirements related to appeals.
* Customer service experience
* Proven ability to problem-solve and make solid and well-researched decisions
* Qualifying criminal background

Licensing/Certification/Education Requirements:

* High school diploma required
* Associates degree preferred
* Successfully completed college courses in relevant field to compensate for experience preferred
* Medicare experience preferred



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