Appeals & Grievances Coordinator

Job Summary

Under the Supervisor’s direction, the Member Appeals and Grievances Department Coordinator assists with all operational aspects of the Member Appeals and Member Grievances process for Commercial, TMP and Public Plans products. Responsibilities include, but are not limited to: distribution and classification of cases in compliance with applicable timeframes and regulations, gathering information on behalf of the specialists with external vendors , coordinating the request for medical records, tracking effectuations, facilitating delivery of appeals and related information to key departments and appeals committee members; analyzing and reporting data regarding department processes as requested from management; note trends in Member Appeals and Grievances and notify supervisors of their findings and ensuring professional handling of Medicare Part D Appeals and Fast Track Appeals timely and in compliance with CMS regulations.

The coordinator must possess broad understanding of all products and benefits as well as have an understanding of regulatory requirements and timeframes. The Coordinator routinely interacts with providers and other internal and external constituents.

Essential functions will occur simultaneously; therefore, the employee must be able to appropriately handle each of these functions, prioritize them, and seek assistance when necessary. These essential functions need to be performed on a consistent and regular basis, using good judgment. The employee must have the ability to learn and apply Tufts Health Plan policies and complex and frequently changing regulatory requirements consistently and the judgment to seek out guidance as needed.

Key Responsibilities/Duties – what you will be doing

• Assign new verbal and written appeals and grievances to Appeals and Grievances specialists
• Enter initial member appeals and grievances data into the system of record and maintain accuracy of appropriate data.
• Review all incoming appeals for potential expedites, assign and notify management as appropriate.
• Reviews and appropriately classifies grievances and appeals
• Track and ensure the timely distribution of all processes addressed by appeals and grievances specialists.

Process Part D Appeals:

• Gather appeal information and criteria information from department systems
• Outreach to providers for additional information in compliance with CMS guidelines
• Summarize and send requests to Medical Directors for decisions
• Complete decision letters and verbal notification of outcomes according to CMS guidelines
• Process cases according to CMS regulations and time frames

Process Fast Track Appeals including:

• Monitors Fast Track appeal phone line and RightFax for new cases and notifies A&G management and Case Management representatives via email
• Corresponds with providers and members as required (timely and accurate correspondence and telephone contact as appropriate).
• Acts as a liaison to Case Management for obtaining discharge summary to complete DENC’s and DNOD’s.
• Completes data entry and documentation requirements in multiple systems.
• Escalates issues to Manager, Supervisors, and Case Manager Supervisors as needed to complete DENC’s, and DNOD’s.
• Responsible for compliance with all CMS and Livanta timelines.

Support the specialists in the completion of appeals and grievances including but not limited to

• Requesting and tracking receipt of appropriate medical records
• Gathering information and uploading to the system of record from external vendors
• Identifying and attaching appropriate sections of member EOCs in the appeals file
• Printing and distributing appeals packets as needed
• Track and complete AOR process
• Develop appeals meeting agendas for the various Appeals Committee meetings.
• Assists in departmental reporting
• Provide in department projects, as assigned

Qualifications – what you need to perform the job

EDUCATION: (Minimum educations & certifications required)

BA/BS or equivalent in health care, administrative or related field preferred.

EXPERIENCE: (Years of experience)

1-2 years of experience in a health care and/or administrative setting preferred.

SKILL REQUIREMENTS: (Include interpersonal skills)

Excellent organizational skills required. Excellent interpersonal/communication skills are essential. Must have computer skills with experience in EXCEL, and WORD. Must have knowledge and demonstrated ability in the use of Windows applications and other comparable systems/applications. Knowledge of basic medical terminology a plus.

Individual must be able to appropriately identify urgent situations and follow the appropriate protocol. Position also requires the ability to manage multiple priorities as well as having the initiative, judgment and perception to operate within a fast paced, high stress environment. Individual must possess strong organizational, logical reasoning, analytical, and problem solving skills as well as the attention to detail necessary to act within this complex environment. Individual must also be able to work independently but be able to identify when they should ask for help. The individual should be flexible in order to respond to changing needs in the Department.

Must be able to work well independently and as a team member. Must be able to work closely with other department staff and must have work coverage plan in place in preparation for scheduled and unscheduled absences, due to importance of position to department’s compliance with various processes.

Requires excellent interpersonal skills and an ability to recognize and understand sensitive customer oriented issues. Position also requires daily contact, by telephone, with members, providers and Tufts HP internal departments.

WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS (include special requirements, e.g., lifting, travel):

• Must be able to work under normal office conditions and in a remote capacity from home as required.
• Work requires simultaneous use of a telephone/headset and laptop/keyboard and sitting for extended durations.
• May be required to work additional hours beyond standard work schedule.
• Weekend Coverage may be required on a rotating basis as regulated for line of business.
• May require occasional weekend hours or evening hours as the needs of the various lines of business dictate.

Disclaimer

The above statements are intended to describe the general nature and level of work being performed by employees assigned to this classification. They are not intended to be construed as an exhaustive list of all responsibilities, duties and skills required of employees assigned to this position. Management retains the discretion to add to or change the duties of the position at any time.

Compensation & Total Rewards Overview

As part of our comprehensive total rewards program, colleagues are also eligible for variable pay. Eligibility for any bonus, commission, benefits, or any other form of compensation and benefits remains in the Company's sole discretion and may be modified at the Company’s sole discretion, consistent with the law.

Point32Health offers their Colleagues a competitive and comprehensive total rewards package which currently includes:

• Medical, dental and vision coverage

• Retirement plans

• Paid time off

• Employer-paid life and disability insurance with additional buy-up coverage options

• Tuition program

• Well-being benefits

• Full suite of benefits to support career development, individual & family health, and financial health

For more details on our total rewards programs, visit https://www.point32health.org/careers/benefits/

Who We Are

Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities.

Scam alert: Point32Health has recently become aware of job posting scams where unauthorized individuals posing as Point32Health recruiters have placed job advertisements and reached out to potential candidates. These advertisements or individuals may ask the applicant to make a payment. Point32Health would never ask an applicant to make a payment related to a job application or job offer, or to pay for workplace equipment. If you have any concerns about the legitimacy of a job posting or recruiting contact, you may contact TA_operations@point32health.org.

This job has been posted by Ignyte AI on behalf of Point32Health. Ignyte AI is committed to the fundamental principle of equal opportunity and equal treatment for every prospective and current employee. It is the policy of Ignyte AI not to discriminate based on race, color, national or ethnic origin, ancestry, age, religion, creed, disability, sex and gender, sexual orientation, gender identity and/or expression, military or veteran status, or any other characteristic protected under applicable federal, state or local law.