Quality Improvement Coordinator (QIC) - Grievances
About The Position
Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together. The Senior Medical Coder performs concurrent review of FFS coding rules within Epic, ensuring all CPT and E/M codes are accurately coded and billed for maximum reimbursement and minimal denials. You will enjoy the flexibility to telecommute from anywhere within the U.S. as you take on some tough challenges.
Requirements
- High School Diploma/GED (or higher)
- 2+ years of experience working with appeals and grievances in healthcare
- 2+ years of experience with medical terminology
- Intermediate level of proficiency with MS Office
Nice To Haves
- Managed care experience
- EPIC experience
Responsibilities
- Receive grievance documentation and determine relevant details
- Review and reconsider determinations regarding whether cases should be reopened after determination has been made
- Make outbound calls to members and/or providers to clarify grievance information
- Determine whether additional grievance reviews are required
- Determine where grievance should be reviewed/handled or route to other departments as appropriate
- Obtain relevant medical records to submit grievance for additional review
- Work with claims or provider groups to clarify determinations and ensure appropriate handling
- Contact and work with other internal resources to obtain and clarify information
- Collect and provide information to support grievance audits
- Research and respond to health plan or regulatory inquiries and/or second level reviews
- Complete grievance review procedures according to relevant regulatory or contractual requirements, processes and timeframes
- Manage case process from start to finish
- Other duties as assigned
Benefits
- comprehensive benefits package
- incentive and recognition programs
- equity stock purchase
- 401k contribution
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What This Job Offers
Job Type
Full-time
Career Level
Entry Level
Education Level
High school or GED
