Grievance & Appeals Coordinator

Job Description : Process grievances and organization determinations, analyze, research, and provide comprehensive responses in accordance with established regulatory and accreditation guidelines. Contact customers to gather information and communicate disposition of case. Conduct pertinent research in order to evaluate, respond to, and finalize case. Familiar with standard concepts, practices, and procedures for analyzing, interpreting data and applying contract and regulatory provisions.

Analyze, research, resolve and respond to confidential / sensitive complaints, grievances and organization determinations from members, member's representatives, providers, media outlets, senior leadership and regulatory agencies with established regulatory and accreditation guidelines.

Make grievance decisions and communicate decision to the claimant within regulatory and accreditation guidelines for timeliness, adhering to the strictest of timeframes for urgent and non-urgent requests, as imposed by the various federal and state laws.

Provide comprehensive grievances responses that support the decision and comply with regulatory and accreditation guidelines, and support the decision by referencing specific and applicable language from the plan documents, certificates, riders, and summary plan descriptions, or the internal rules, guidelines and protocols, as appropriate.

Analyze, research, resolve and respond to high level inquiries, referrals and complaints received from various regulatory agencies and other sources.

Maintain thorough knowledge of internal policies, procedures, regulations, charters for accurate resolution of complaints and grievances, including existing laws and regulations and new ones.

Remain up-to-date in the use of internal systems as well as vendor systems.

Perform other duties as requested.

Qualifications"

• Bachelor's degree required with a major in Health Care Administration, English, Communications, or related field preferred.
• Two (2) years customer service experience required.
• Two (2) years health insurance experience and familiarity with health insurance state and federal regulations preferred.
• Strong project management skills preferred including management of personal inventory.
• Strong analytical, critical thinking, organizational, time management and problem resolution skills.
• Excellent verbal and written communication skills.
• Strong PC applications (i.e. Microsoft Excel, Word, and Outlook).
• High regard for protecting confidentiality of corporate information.
• Proven ability to foster and maintain open, collaborative and constructive relationships within internal, external and leadership to achieve departmental and corporate results.
• Ability to apply policies and procedures to arrive at accurate conclusions.
• Ability to analyze, interpret, apply reason and logic, conduct research structure a clear and thorough response.
• Ability to quickly learn and navigate diverse products and information systems.
• Other related skills and / or abilities may be required to perform this job.
• An understanding of MA servicing structure related to grievance and appeals or experience in claims with the ability to apply EOC research in prepping cases preferred.
• Previous experience with Health Insurance preferred.
• Demonstrates one can handle multiple tasks / projects concurrently with minimal supervision

Medicare Advantage

1. Accountable for CMS Chapter 13, CMS Audit Compliance and Star Quality Measures : a.Member rights, b.Timely decisions about appeals, c.Fairness of the health plan's appeal decisions based on an independent reviewer

2. Data entry accuracy is required.

3. Full understanding of Medicare Advantage servicing environment is preferred.

All qualified applicants will receive consideration for employment without regard to, among other grounds, race, color, religion, sex, national origin, sexual orientation, age, gender identity, protected veteran status or status as an individual with a disability.