Reporting to the Supervisor, Appeals and Grievances, this position is responsible for the administrative tasks for coordination of member and/or provider appeals; the analysis of claims and appeals; and the review of medical management authorizations.

• Research and Investigate member and/or provider appeals and grievance requests, includes review of UM/claim denial reasons, contract/regulatory rules, benefits and documentation received on appeal/grievance
• Outreach call(s) made to members/participants, providers and /or member/participant representatives, to acknowledge receipt of appeal/grievance and discuss intent of appeal/grievance
• Explain the appeal/grievance process including helping members understand the outcome and implication of appeals decisions
• Prepares case file (original denial, all information received on appeal, medical records, etc.)
• Schedule participant/member for committee panel sends scheduling letter if needed
• Prepares, develops and presents written case summaries, if needed and process dictates, for all adverse determination for the purpose of conducting State Fair Hearings
• Prepare and send cases files to other teams as needed (e.g. legal, external appeals, state fair hearings, etc.)
• Communicates updates and status of outstanding member and provider complaints/issues to management
• Monitors to ensure that all problems with appeals/grievances presented by plan members/participants are resolved in accordance with established policies and procedures
• Update and/or generate authorization updates requests, for services that have been appealed
• Maintains accurate, timely, and complete record of appeals and grievances in the appeals system and documents, all correspondence with a member/participant, representative and/or a provider, related to an appeal or grievance issue
• Maintains quality and compliance standards as dictated by the state and federal entities
• Maintains contractual agreements with participating providers related to appeals and grievances
• Monitors caseload daily to ensure all cases are kept within compliance; follows up and escalates when compliance standards are at risk
• Actively seeks the involvement of the legal department or compliance department, as necessary, for clarification and supporting documentation by escalating issues to appeals and grievances management
• Obtain authorization for release of sensitive and confidential information
• Keeps current with rules, regulations, policies and procedures relating to Plan member benefits, member’s rights and responsibilities, and Complaints and Grievances
• Ensure case file is sent to appropriate committee for decision making or example, internal committee/panel, independent review organization, internal medical director - as process dictates
• Provide support presenting cases and facilitating committee meetings as needed
• Send appeal to an independent review organization portal, for those appeals that require an external match specialty review
• Obtain data from multiple systems/vendors to ensure all documentation needed for appeal is obtained, for e.g. PerformRX, LTSS and other systems/vendors as needed
• Collaboration with internal counterparts as needed to ensure proper handling of the appeal e.g. UM team, medical directors, claims, contact center, vendors as needed (e.g. PerformRX)
• Creates decision letter with detail description of the nature of appeal / grievance including rational for the decision and options for moving forward
• Initiate and follow up on effectuations (um authorization update/claim adjustment) for overturned appeals/grievances
• Keeps current with rules, regulations, policies and procedures relating to Plan member benefits, member’s rights and responsibilities, and Complaints and Grievances
• Ensure case file is sent to appropriate committee for decision making or example, internal committee/panel, independent review organization, internal medical director - as process dictates
• Provide support presenting cases and facilitating committee meetings as needed
• Send appeal to an independent review organization portal, for those appeals that require an external match specialty review
• Obtain data from multiple systems/vendors to ensure all documentation needed for appeal is obtained, for e.g. PerformRX, LTSS and other systems/vendors as needed
• Collaboration with internal counterparts as needed to ensure proper handling of the appeal e.g. UM team, medical directors, claims, contact center, vendors as needed (e.g. PerformRX)
• Creates decision letter with detail description of the nature of appeal / grievance including rational for the decision and options for moving forward
• Initiate and follow up on effectuations (um authorization update/claim adjustment) for overturned appeals/grievances.

Education/ Experience:

• High School/GED
• A minimum of two (2) years’ work experience in a Managed Care environment and knowledge of the basic health care industry, managed care principles and medical terminology preferred
• 1 to 3 years experience
• Strong telephone soft skills
• Proficiency and knowledge of Windows and Microsoft Office applications, including Excel, Access, PowerPoint and Outlook
• Good verbal and written communication skills
• Experience in grievance/appeals environment preferred.

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