Appeals and Grievance Coordinator
3 weeks ago
JOB TITLE: Appeals and Grievance Coordinator FLSA STATUS: Non-Exempt
DEPARTMENT: Appeals and Grievances
REPORTS TO: Supervisor, Appeals & Grievances
JOB SUMMARY: Responsible for reviewing and resolving member complaints and appeals and communicating resolution to members in accordance with the standards and requirements established by Medicare and applicable state insurance regulations for the Exchange.
ESSENTIAL JOB FUNCTIONS:
Responsible for providing administrative support to ensure grievance and appeal cases are processed per regulatory guideline and internal department protocol including:
Coordinate, document and track all members, grievances and member and provider appeals and or grievances.
Generates written correspondence to members and providers and using appropriate grammar and punctuation.
Ensure all grievance and appeal communications are sent out within regulatory compliance guidelines.
Researches issues utilizing internal systems, outreach to providers, vendors and internal departments in order to fully respond to all issues raised in a grievance or to resolve appeal.
Requests medical records, clinical notes, and responses from providers, vendors and internal departments as needed.
Maintains working knowledge of regulatory guidelines surrounding grievances and appeals per Medicare and state regulations and per internal A & G policies & procedures.
Acts as a liaison between departments to coordinate information and close grievances and appeals within regulatory timelines.
Keeps A & G leadership aware of open & pending grievance and appeal cases and expected resolution measures.
Adheres to payroll policies and properly uses timekeeping system with minimal manual changes.
Maintains regular and consistent attendance.
Adheres to Compliance Plan and HIPAA regulations.
MARGINAL JOB FUNCTIONS:
Takes on special projects as needed.
Performs other duties as assigned.
BEHAVIORAL EXPECTATIONS:
1. Continuous Learning:
a. Attends staff meetings as required.
b. Attends appropriate training, seminars and workshops as required.
2. Customer Focus:
a. Maintains client/customer confidentiality and privacy in accordance with HIPPA regulations
and IMASs Standards of Conduct.
b. Fosters appropriate communication and relations with Supervisor, co-workers, and other staff.
3. Quality/Process Improvement/Safety
a. Reports issues of security, health and/or safety to appropriate supervisor as soon as practicable.
b. Supports and demonstrates safety throughout all duties performed.
c. Follows established policies and procedures and understands and complies with all regulators
standards set forth by governing entities.
POSITION REQUIREMENTS:
EDUCATION/EXPERIENCE:
High school graduate or equivalent.
1 year of Medicare A&G experience required.
Must have experience in making outgoing phone calls as well as taking incoming phone inquiries
SKILLS/KNOWLEDGE/ABILITY:
Proficiency with Microsoft Office Suite: Word, Excel, Outlook, and Power Point.
Solid ability to prioritize tasks and manage multiple tasks simultaneously.
Ability to read, write, speak, and understand English proficiently.
Exercises excellent written, verbal, listening and interpersonal communication skills necessary to effectively interact with all levels of internal and external parties, to convey information correctly, and manage challenging situations.
Strong attention to quality and detail.
Excellent communication skills necessary to provide accurate information to members and collaborating staff.
Ability to analyze information provided.
Willingness and ability to interact professionally with all customers, members, and co-workers, individually and as part of a team.
Adheres to maintaining high level of confidentiality and privacy.
Willingness and ability to make appropriate judgments, decisions and problem solving in a timely manner and within the context of the situation at hand.
Willingness and ability to take initiative and be a self-starter.
Willingness and ability to understand and comply with Federal, State, and local regulations.
LICENSURE/CERTIFICATE/TRAINING:
n/a
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