What are the responsibilities and job description for the Submission for the position: Appeals and Grievance Specialist - Commercial Plans - (Job Number: 24017296) position at Baylor Scott & White Healthcare?
JOB SUMMARY
Hybrid position - Temple, TX
The Appeals and Grievance Specialist performs reviews, within operational aspects, of the member and provider complaints, appeals and grievance cases for products for all lines of business. Responsibilities include, but are not limited to : timely classification and resolution of cases; review, research and coordination of complaints, grievances, appeals and reconsiderations consistent with statutory and federal regulatory guidelines.
ESSENTIAL FUNCTIONS OF THE ROLE
- Maintains data entry requirements for all complaints, appeals and grievances.
- Builds case files for each complaint, appeal and grievance, and ensures compliance with organizational and regulatory guidelines.
- Investigates providers and members or authorized representatives concerns and disputes for all lines of business. Contacts members and providers to gather information and communicate disposition of cases. Consults with health care providers, vendors, legal representatives, medical, and staff administration, and accurately documents all communication with involved parties. Reviews details submitted by members and providers; verifies classifications and enters information into the data management tracking system.
- Maintains case assignment worklist assuring cases are on track and closed within the regulatory turn around time.
- Coordinates activities for all expedited and external case reviews, and prepares final case submissions.
- Refers clinical appeal cases to Medical Nurse Auditors or Pharmacy Technicians for handling where required.
- Ensures case closure correspondence is generated in accordance with regulatory and statutory requirements and in response to instructions from external review entities.
- Chairs and coordinates participation at appeal panel hearings, e.g. coordinates with members of panel, provides information prior to hearing, assures scheduling and physician follow-up to ensure attendance, as appropriate.
KEY SUCCESS FACTORS
BENEFITS
Our benefits are designed to help you live well no matter where you are on your journey. For full details on coverage and eligibility, visit the Baylor Scott & White Benefits Hub to explore our offerings, which may include :
Note : Benefits may vary based upon position type and / or level
QUALIFICATIONS
