Grievance & Appeals - Grievance & Appeals Coordinator 201-1008

About the role

Responsible for all written inquiries from members seeking resolution through the grievance and appeals process.

Responsibilities

• Researches member issues and prepares grievance and appeals information for each level of the appeal process.
• Responsible for adhering to established grievance and appeals timeframes.
• Assures compliance with Federal, State and Accreditation regulations.
• Receives and responds to member and/or provider written and oral complaints and requests in accordance with CommunityCare's grievance and appeals procedures.
• Ensures appropriate file documentation that demonstrate process steps.
• Interacts with Medical Management, Member Services, Claims, Pharmacy, Provider Services as well as Senior Management to resolve issues.
• Interacts with members, providers, and attorneys who represent the member regarding the grievance and appeals process.
• Interacts with Center for Medicare and Medicaid Services (CMS) and MAXIMUS Federal Services as indicated.
• Ensures the grievance and appeals electronic tracking system (GATS) is populated correctly and completely for each case.
• Participates in the audit process.
• Notifies members and/or providers in writing of the decision made at each level of the appeal process.
• Coordinates with the Claims, Pharmacy helpdesk and or Medical Management to ensure that authorization is obtained and claim payment is processed, if indicated.
• Prepares grievance and appeal files for audit.
• Assist Supervisor with special projects and CMS quarterly reports as it relates to Grievance and Appeals.
• Explains policies, procedures, available benefits and service options to members and/or providers related to the grievance and appeals process.
• For inquiries forwarded from the Department of Insurance, adheres to all specified communication and timeframe requirements. Documents accordingly in the file.
• Work may involve dealing with members who are disgruntled or upset.
• Perform other job-related duties as assigned.

Qualifications

• Customer service experience in managed care, insurance or healthcare environment required.
• Successful completion of Health Care Sanctions background check.
• Possess strong oral and written communication skills.
• Ability to work on multiple tasks.
• Proficient in Microsoft applications.
• Highly organized and attentive to detail.

Education/Experience

High school diploma or equivalent PLUS 5 years related experience OR Associates degree plus 1 year of related experience required. Related experience consists of customer service, member service or claims processing in an insurance environment. Managed care experience preferred.