Appeals and Grievance Coordinator

About the role

This position is accountable for the comprehensive review, research and resolution of appeals and grievances submitted by both members and providers. This position is required to apply analytical and critical thinking when reviewing contract language, benefits, and covered services in researching and providing an accurate and appropriate resolution in accordance with the Centers for Medicare and Medicaid Services (CMS) and the state of Nevada Division of Insurance.

Responsibilities

• Review and evaluate Medicare, Commercial and Self-Funded appeal requests in order to identify and triage member and provider appeals.
• Determine eligibility, benefits, and prior activity related to the claims payment or service denial issues related to Medicare appeal requests using internal systems.
• Complete cases within CMS and DOI regulations.
• Request and review medical records, notes, and/or detailed bills as appropriate; formulate conclusions per protocol and other business partners to determine response; assure timeliness and appropriateness of responses per state, federal and Hometown Health guidelines.
• Prepare case files (original denial, all information received on appeal, medical records, and case summary for external reviewers, DOI, 2nd level review committee, OCHA, and/or arbitrators).
• Prepare, develop, and present written case summaries, if needed and process dictates, for all adverse determinations for the purpose of litigation and arbitration.
• Maintain accurate, timely, and complete record of appeals and grievances in the appeals system and documents, all correspondence with a member/provider related to an appeal or grievance issue.
• Facilitate comprehensive processing of Medicare appeals to independent review organization (IRO) timely to meet regulatory turnaround times and protect our CMS Star Ratings.
• Achieve a high level of workload volume, ensuring accuracy and compliance to scheduled regulatory deadlines.
• Monitor caseload daily to ensure all cases are kept in compliance, follows up and escalates when compliance standards are at risk.
• Escalates to manager when in need of the involvement of the legal department or compliance department for clarification and supporting documentation.
• Initiate and follow up on the effectuations (UM authorization/claim adjustment) for overturned appeals/grievances.
• Refer matters that involve problems that can develop negatively towards Hometown Health or matters affecting the department’s operating and capital budgets directly to Leadership.
• Collaborate with all Hometown Health departments, members, employers, brokers and providers and high standards of courteousness, performance, diplomacy, and respect for confidentiality.
• Collaborate with clinical staff for clinical related questions or issues.
• Review and evaluate all grievances, appeals and complaints submitted to the organization while adhering to established timelines and initiate electronic tracking and distribution to the appropriate department for resolution.
• Responsible for timely completion of all audit findings on appeals to ensure accurate appeal and grievance universes can be supplied upon request.
• Identify and keep management informed of themes and/or trends related to service and recommend solutions to these issues.
• Identify complex problems and provide a resolution as it pertains to appeals and grievances.
• Participate in the development of Standard Work to improve the quality and service to our customers.

Qualifications

• Required: Bachelors’ Degree in Business Administration or related field preferred, but will consider collective experience, training, and education.
• Experience: Three years’ experience processing health insurance appeals and grievances or equivalent experience in health insurance claims, customer service, billing, or related operations preferred.
• Knowledge: Strong knowledge of claims operations and health plan customer service policies, procedures, and systems. Medicare experience preferred. Knowledge of state and federal insurance regulations with emphases on the Centers for Medicare and Medicaid Services (CMS).
• Skills: Excellent verbal and written communication and organizational skills. Strong knowledge of medical billing practices to include, but not limited to medical terminology, CPT ICD9/10, and HCPCS coding. The ability to communicate professionally and diplomatically, clearly, and concisely, both verbally and in writing. The ability to maintain confidentiality of medical and personal information of all customers. The ability to ensure all goals and deadlines are met. Demonstrated skills in problem identification, problem solving and process improvement.