Grievance & Appeals - Grievance & Appeals Coordinator II 201-1007

CommunityCare•Tulsa, OK

About The Position

JOB SUMMARY: Responsible for all inquiries from members and providers seeking resolution through the grievance and appeals process. KEY RESPONSIBILITIES: Investigates complaints and communicates resolution to member (or authorized representatives) for all lines of business in accordance with CommunityCare’ s grievance procedures. Investigates; prepares case files and presents cases for medical and/or administrative review. For all lines of business for post-service claims appeals and standard pre-service claims appeals. Assures compliance with Federal, State and Accreditation regulations and CommunityCare’ s appeal procedures and timeframes. Prepare higher level appeal case packets. Interacts with Medical Management, Member Services, Claims, Pharmacy, Provider Services as well as Senior Management to resolve issues and other internal process owners as indicated. 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 and other regulatory entities as indicated. Maintains appropriate file documentation that demonstrates process is followed and accurately entered in the system. 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 received from the Department of Insurance, adheres to all specified communication and timeframe requirements. Work may involve dealing with members who are disgruntled or upset. Perform other duties as assigned.

Requirements

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 reason logically and to use good judgment when interpreting materials or situation.
Ability to organize time effectively and set priorities.
Proficient in Microsoft applications.
Highly organized and attentive to detail.
High school diploma or equivalent PLUS 3 years related experience OR associate degree plus 2 years of related experience required.
Related experience consists of customer service, member service or claims processing in an insurance environment.

Nice To Haves

Managed care experience preferred.

Responsibilities

Investigates complaints and communicates resolution to member (or authorized representatives) for all lines of business in accordance with CommunityCare’ s grievance procedures.
Investigates; prepares case files and presents cases for medical and/or administrative review.
Assures compliance with Federal, State and Accreditation regulations and CommunityCare’ s appeal procedures and timeframes.
Interacts with Medical Management, Member Services, Claims, Pharmacy, Provider Services as well as Senior Management to resolve issues and other internal process owners as indicated.
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 and other regulatory entities as indicated.
Maintains appropriate file documentation that demonstrates process is followed and accurately entered in the system.
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 received from the Department of Insurance, adheres to all specified communication and timeframe requirements.
Work may involve dealing with members who are disgruntled or upset.
Perform other duties as assigned.