Quality Improvement

2 weeks ago

Tulsa, Oklahoma, United States CommunityCare Full time $45,000 - $65,000 per year

JOB SUMMARY:

This position is responsible for supporting the grievance and appeals activities pertaining to all written inquiries from members and providers requesting resolution through the grievance and appeals process. This includes claims and authorization research.

KEY RESPONSIBILITIES:

  • Is the Lead for triage of all Medicare requests to ensure compliance with complex Medicare requirements related to appeals. This includes, requesting required information and following up with members and providers regarding release of information, appointed representative, waiver of liability and good cause explanation. Dismissing appeal requests that are not valid per CMS regulation and preparing notification of appeal status. Ensures appropriate case documentation that demonstrate process steps.
  • Open, date stamp and disseminate all mail for the department, data entry of requests and attaching documents to data base.
  • Crossed trained to perform G&A Coordinator functions related to processing grievances and appeal requests as needed when volume as high.
  • Explains policies, procedures, available benefits, and service options to members and/or provider related to the grievance and appeals process.
  • Assist Manager and supervisor with other projects and duties as assigned.

QUALIFICATIONS:

  • Possess strong oral and written communication skills.
  • Ability to reason logically and to use good judgment when interpreting materials and situations.
  • Successful completion of Health Care Sanctions background check.
  • Ability to organize time effectively and set priorities.
  • Ability to work effectively with personnel at all levels within the company.
  • Proficient in Microsoft Office applications.

EDUCATION/EXPERIENCE:

  • High School Diploma or equivalency.
  • Four to five years' experience in office, managed health care, health insurance or health facilities preferred.

CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age, race, religion, color, disability, sex, sexual orientation or national origin

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