The Appeals & Grievances Coordinator is responsible for the processing, tracking and follow up of all grievances, medical necessity and administrative denials and appeals. This individual is required to have excellent communication and organizational skills. Must possess the ability to work cooperatively with health plan Appeal Divisions, such as CMS, AHCA and other federal and state regulatory agencies. Coordinator must present excellent customer service to providers and members, and the ability to perform in potentially stressful situations. Key Responsibilities:
Maintain a current knowledge of plan products, policies and procedures with the ability to relate this information in a clear, concise and understandable manner to member, providers, and other customers, both internal and external
Maintains systems and processes for the timely and accurate resolution of all grievances, medically necessary and administrative appeals and ensuring compliance with all relevant regulations, accrediting standards, policies and procedures
Manage the receipt, investigation and resolution of standard complaint and appeal issues in a timely and highly effective manner
Interface with the appropriate management and staff at all levels to present and summarize grievances and Appeal cases
Maintain confidentiality of all protected health information in accordance with state and federal guidelines and corporate policies and procedures
Maintain knowledge of all system, contractual, compliance standard changes and policy updates, and attend additional training sessions as necessary
Complete projects and other research tasks as assigned by area management
Maintains up to date Appeal Logs and Appeal Files that are in compliance with CMS, AHCA and all other federal, and state regulatory agencies
Other duties as assigned
Qualifications:
High school diploma, GED or equivalent work experience.
1+ years of customer service experience.
Excellent verbal and written communication skills.
Strong letter writing and prooing skills.
Analytical, having the ability to examine a matter, the facts, contextual information and make an informed decision or implement and execute a reasonable, rational resolution.
Ability to work in a fast-paced environment with tight deadlines and high-quality standards.
Note: This description indicates, in general terms, the type and level of work performed and responsibilities held by the team member(s). Duties described are not to be interpreted as being all-inclusive or specific to any individual team member.
No Third Party Agencies or Submissions Will Be Accepted.Our company is committed to creating a diverse environment. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status. DFWPOpportunities posted here do not create any implied or express employment contract between you and our company / our clients and can be changed at our discretion and / or the discretion of our clients. Any and all information may change without notice. We reserve the right to solely determine applicant suitability. By your submission you agree to all terms herein. Powered by JazzHR
