Quality Improvement - Grievance & Appeals Coordinator I_195-1007

JOB SUMMARY:

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

KEY RESPONSIBILITIES:

• Investigates member 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 non-complex post-service claims appeals. Assures compliance with Federal, State and Accreditation regulations and CommunityCare’ s appeal procedures and timeframes.
• Explain policies, procedures, available benefits, and service options to members related to the grievance process.
• Adheres to established grievance timeframes. Assures compliance with Federal, State and Accreditation regulations.
• Maintains appropriate file documentation that demonstrates process is followed and accurately entered in the system.
• 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, authorized representatives and attorneys who represent the member regarding the grievance process.
• Interacts with Center for Medicare and Medicaid Services (CMS) and MAXIMUS Federal Services as indicated.
• Participates in the audit process. Prepares grievance files for audit. Assist Supervisor with special projects and CMS quarterly reports as it relates to Grievances.
• Work may involve dealing with members who are disgruntled or upset.
• Perform other duties as assigned.

QUALIFICATIONS:

• Customer service experience in managed care, insurance or healthcare environment required.
• Successful completion of Health Care Sanctions background check.
• Ability to reason logically and to use good judgment when interpreting materials or situations.
• Possess strong oral and written communication skills.
• Ability to organize time effectively and set priorities.
• Proficient in Microsoft applications.
• Highly organized and attentive to detail.

EDUCATION/EXPERIENCE:

• High school diploma or equivalent plus 2 years related experience OR associate 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.