Senior Coordinator, Grievance & Appeals

What We Provide

• Referral bonus opportunities
• Generous paid time off (PTO), starting at 20 days of paid time off and 9 company holidays
• Health insurance plan for you and your loved ones, Medical, Dental, Vision, Life and Disability
• Employer-matched retirement saving funds
• Personal and financial wellness programs
• Pre-tax flexible spending accounts (FSAs) for healthcare and dependent care
• Generous tuition reimbursement for qualifying degrees
• Opportunities for professional growth and career advancement
• Internal mobility, generous tuition reimbursement, CEU credits, and advancement opportunities

What You Will Do

• Identifies case types (e.g.- clinical vs non-clinical appeals) during the intake process, communicates and responds to department inquiries such as case status. Initiates follow up emails when additional information is required.
• Identifies and coordinates clinical appeal documentation needed for review by the G&A RNs by preparing cases, ensuring all pertinent information is included in the case file. Conducts preliminary review to determine the case level and type and notates the findings in the case. Uploads and documents in tracking database, identifies key information. Assigns cases according to established department process.
• Assists with triaging cases for valid appeals and moving out of triage accordingly. Tracks the chain of custody of case records in and out of the department, according to established procedures. Maintains confidentiality of information.
• Maintains knowledge of Grievance and Appeals (G&A) procedures, and CMS and DOH regulatory requirements and timeframes, and prioritizes work accordingly.
• Assists with identifying and researching missing data elements in the various systems that are necessary for the G&A database, including providing follow-up support to the RNs in obtaining Initial Adverse Determinations notices.
• Prepares clinical cases sent for the external reviews consistent with established procedures. Assists with entering the case into the Independent Review Entity (IRE) log, tracking receipt, ensuring that the reply is reviewed by the staff and implementing action as appropriate.
• Prepares and issues templated letters, including but not limited to acknowledgment letters, extension notices, clinical appeal decision letters and notices to non-contracted providers requesting the Waiver of Liability form, follows-up and tracks receipt. Prepares letters requesting Appointment of Representative (AOR) forms in grievances and appeals filed on behalf of member representatives. Prepares letters requesting Waiver of Liability (WOL) forms in appeals filed by non-participating providers. Follows up with members and the providers via telephone and mail to request timely access to waiver of liability and AOR forms as needed.
• Assists with updating of authorization related to overturned and partially overturned cases.
• Assists with communicating, and preparing / sending case files to external entities related to the appeals level II process such as External Appeals, Fair Hearings, and the IRE.
• Collaborates with the clinical team to ensure appropriate notices and follow ups are performed and the third party administrator staff to facilitate appropriate case files and updates are sent. Also collaborates with internal department staff with respect to inquiries, case status, or requesting additional information.
• Recommends improvements in the effectiveness or efficiency of workflows for improved departmental operations and timely customer service.
• Participates in special projects and performs other duties as assigned.

Education:

• Associate's Degree in business administration, health care or related discipline or the equivalent work experience required
• Bachelor's Degree in business administration, health care or related discipline preferred

Work Experience:

• Minimum of three years of administrative support experience in a health care organization required
• Knowledge of DOH and CMS Grievance and Appeals regulatory requirements and procedures for ensuring compliance preferred
• Proficient PC skills, including MS Excel, Word, and Access required
• Knowledge of Facets system preferred