Appeals and Grievance Specialist II - HP Appeals Grievances

Description

Summary:

This position requires the ability to work independently researching and reviewing inquiries from members and providers. Also requires knowledge of benefit interpretation, claims reviews, CPT and ICD coding. Responsible for reviewing, classifying, researching and resolving member complaints (grievances and/or appeals) and communicating resolution to members or their authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid Services and TRICARE. Coordinates with pertinent departments to effectuate resolution resulting from grievance and appeals resolution decisions made at the plan level or by independent review entities. Adheres to CHRISTUS Health Plan policies and procedures which are based on regulated state and federal policies pertaining to the processing of grievances and appeals. Analyzes grievance and appeals data and develops tracking and trending reports at prescribed frequencies for the explicit purpose of identifying and communicating trended root causes of member and provider dissatisfaction. Recommends process improvements to pertinent departments within the CHRISTUS Health Plan organization in order to achieve member and provider satisfaction and/or operational effectiveness and efficiencies which contribute to maximum Medicare STAR ratings. 

Responsibilities:

• Research and provide resolution to issues such as claim denials, member and provider complaints, and reconsideration and redetermination requests. 


• Integrate and analyze information from several sources and problem solve towards a resolution within tight timelines. 


• Be able to summarize and communicate a member or provider case to others for the purpose of facilitating a fair decision and fulfilling standards and requirements of the regulatory agency. 


• Interact well with both internal and external customers along with strong organizational and time management skills. 


• Abilities to interpret and communicate data and trends to a management audience. 


• Proficient in Word and Excel. 


• Knowledge of medical terminology, Medicare coding and Medicare-covered benefits preferred. 


• Excellent verbal and written communication skills. 


• Ability to maintain attendance to support required quality and quantity of work. 


• Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers. 


• Be proactive in educating members, providers and others about CHRISTUS Health plans appeal/grievance process, plan terminations, contract terminations and benefit summary.


• Certify that providers and members are reimbursed accordingly using Medicare or other applicable plan reimbursement policies and procedures. 


• Maintain accurate and timely responses to inquiries and generate appropriate letters to members and providers informing them of appeal/grievance decisions. 


• Provide recommendations and direction to both servicing providers and members in attempt to eliminate repeated disputes between providers and CHRISTUS Health Plan.  


• Follow the CHRISTUS Health guidelines related to Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI). 


• Attend weekly and monthly team and department meetings as appropriate.


• Ability to sit for long periods of time. 


• Ability to organize and prioritize work to meet deadlines. 


• Ability to work occasional long or irregular hours. 


• Ability to work flexible work schedule including evenings and weekends.  

Requirements:

Education/Skills: 

• Associate Degree Preferred. 


• Previous Appeals and Grievance experience with Managed Care Plans. 


• Good typing and letter writing skills. 


• Excellent written and oral communication skills. 


• Excellent research and analytical skills. 


• Basic computer knowledge. 


• Excellent customer service skills.


• Ability to work well with diverse groups of individuals.


•  Utilizes effective communication and conflict management skills. 

Experience: 

• Minimum of three years customer service experience with Managed Care Plans. 


• Minimum of two years appeal and grievance experience with Managed Care Plans. 

Licenses, Registration, or Certification:

• Not applicable  

Work Schedule:

5 Days - 8 Hours

Work Type:

Full Time