Appeals and Grievances Coordinator

Responsible for the research, coordination, and documentation of written and verbal grievances/appeals filed by members/providers. This includes the beginning-to-end process in accordance with the standards and requirements established by various regulators. Examples include but are not limited to CMS, BMS, DOI, NCQA and EQRO.

Required:

1. High school diploma: college preferred.
2. Detail oriented.
3. Excellent customer services skills.
4. Ability to work independently and as part of a team.
5. Excellent time management skills with the ability to meet regulatory guidelines.
6. Proficient in Microsoft Office products.
7. Ability to review, understand and apply the provisions of policies, procedures, and benefit provisions.

1. Knowledge of managed care, state and federal guidelines and regulations.
2. Previous experience in managed care setting.
3. Familiar with medical terminology, ICD 10, and CPT coding.

1. Responsible for handling of assigned appeals and grievances by inputting into appropriate databases, writing acknowledgment letters, obtaining medical records as needed, researching cases, resolving issues, and submitting resolution letters while ensuring that regulatory time frames are met.
2. Responds timely to inquiries from authorized representatives, providers and appropriate internal staff regarding appeals and grievances.
3. Works closely with other departments to research and resolve member/provider appeals and grievances.
4. Contact providers and other external agencies to obtain additional supporting documentation to adequately resolve and respond to appeals and grievances.
5. Responsible for investigating and resolving all priority appeals and/or concerns in a timely and efficient manner.
6. Adheres to all policies and procedures and ensures all guidelines set forth by regulatory bodies are followed and met.
7. Accurately logs, tracks and processes appeal and grievances into the OICS platform accordingly.
8. Maintains concise documentation associated with the processing and handling of appeals and grievances to comply with regulatory standards and timeframes while maintaining accurate and complete records in OICS database.
9. Presents ideas for performance and process improvement changes to supervisor.
10. Notifies supervisor of identified appeal and grievance patterns, claim errors or systemic problems that may be identified during the appeal and grievance review process.
11. Prepares case files to present to Appeal Committee by LOB, Maximus Federal Services and C2C Innovative Solutions for pharmacy.
12. Notifies members/providers of the outcome of their appeal and the next step process once the appeal process through The Health Plan has been exhausted, if applicable.