The Appeals & Grievances Specialist is responsible for supporting the Medical Management Department regarding clinical A&G issues.
The purpose of this position is for the coordination, management, and resolution of denied claims, appeals and grievances and for the processing and coordination of all levels of member and provider medical appeals, payment appeals and dispute activities.
· Identifies, coordinates and routes medical appeals accurately and timely.
· Initiates case files for each appeal and ensures compliance with organizational and regulatory requirements.
· Responds to complaints, grievances and appeals in a consistent fashion, adhering to all regulatory, accreditation and internal processing timelines and guidelines
· Provides all administrative related information and routes accordingly for proper clinical review
· Responsible for the timely and accurate documentation of the grievance or appeal both electronically and in hard copy.
· Responds to written and/or verbal grievances, complaints and appeals submitted by members and providers in accordance with the regulations of the CMS, DOH and other entities.
· Conducts thorough investigations of all related member and provider correspondence through a comprehensive fact finding review to understand all the issues involved.
· Obtains responses and required information from internal and external entities accordingly.
· Prepares detailed written responses to all member and providers regarding the resolution of the submission
· Interfaces with various departments (claims, provider relations, etc.) delegated entities, Medical Groups and Network Physicians to ensure timely resolution of cases when additional discussions are required to assess submitted appeal.
· Determines proper response based on type of Grievance or Appeal submitted using independent judgment.
· Provides written acknowledgment of all member and provider correspondence to be utilized during investigations.
· Monitors daily and weekly pending report
· Prepares all initial and final adverse determination letters.
· Tracks status of appeal and findings in designated tracking systems
· Documents all activities/ notes in designated system
· Provides weekly/monthly Medical Management analysis/ finance reports for management team.
· Prepares reports for presentation at various committee MM Committee minutes and distributes to Committee Team Members
· Prepares quarterly Medical Management Committee meeting binders
· Adheres to company and department policies and procedures.
· Performs other duties as assigned.
· Demonstrated ability to manage multiple projects and be flexible.
Education: Bachelors or Associates Degree in business, health care or related field.
Experience: Two years experience in a managed care healthcare setting with experience
in Appeals and Grievances and claims.
Other: Proficient in computer programs such as Microsoft Office, Microsoft Excel, and
knowledge of Access or other database programs a plus.
Excellent verbal and written communication skills
Excellent problem solving and analytical skills
Accurate attention to detail with strong organizational skills.
Demonstrated ability to manage multiple projects and be flexible.