Appeals and Grievance Specialist I

Job Purpose

The Appeals and Grievance Specialist I is responsible for ensuring professional handling of all member and provider reconsiderations in a timely and efficient way. The Specialist must possess broad understanding of all products and benefits as well as an understanding of regulatory requirements and timeframes. Specialists routinely interact with internal constituents about highly escalated issues.

Duties and responsibilities

• Receives and performs initial research on member and provider reconsiderations
• Categorizes each reconsideration appropriately

Completes data entry and documentation requirements in multiple systems

• Acts as a liaison and coordinates functions with internal departments relative to the status of a member or provider reconsideration and the research needed to prepare the case for review
• Prepares and presents cases to the Director of Claims and any appropriate committees
• Responsible for meeting all regulatory and department timelines
• Responsible for researching and responding to legal requests
• Reviews and responds to appeals for timely submission for assigned thresholds
• Reviews and responds requests for retro prior authorizations for assigned thresholds
• Participates on team projects and special assignments as needed
• Identifies systematic procedural issues and initiates action to resolve those issues, while maintaining documentation of all findings and actions taken
• Meets assigned deadlines and effectively communicates with all levels of staff and management
• Maintains knowledge of provider contracts, plan policies and coverages, claim processing guidelines and systems, and an overall understanding of operational workflow processes
• Works closely with other departments to gather information
• Assists Appeals Resolution Clerk with clarification and maintenance of appeal triaging
• Maintains regular and predictable attendance
• Consistently demonstrates compliance with HIPAA regulations, professional conduct, and ethical practice
• Maintains work area in a clean and orderly condition and ensures safe operating conditions within area of responsibility
• Works to encourage and promote Company culture throughout the organization - waiting on this to be approved

Qualifications

High School Diploma or GED required

Associates or Bachelor's degree preferred

Two to three years of office experience with emphasis in customer service required

• Knowledge of ICD-10, CPT4 Coding, HCPCS and medical terminology
• Experience with Word and Excel
• Effective interpersonal/communication skills are essential
• Competencies
• Ethics - Honest, accountable, maintains confidentiality

Additional information

• Reliability - The extent to which the employee can be depended upon to be available for work, do it properly, and complete it on time. The degree to which the employee is reliable, trustworthy, and persistent.
• Sense of Urgency - Meets deadlines, establishes appropriate priority, gets the job done in a timely manner
• Organization Skills - Information organized and accessible, maintains efficient workspace, manages time well
• Computer Skills - Skilled with computers, takes advantage of new technology, learns new tools quickly, uses technology to enhance job performance
• Communication Skills - Possesses effective communication skills: oral, written, listening
• Productivity - Manages workload, works efficiently, meets goals and objectives
• Initiative - Takes action, seeks new opportunities, strives to see projects to completion
• Planning & Organizing - Displays ability to effectively plan, organize and implement applicable tasks or projects in relation to established goals and objectives
• Quality - Strives to eliminate errors, accurate work is a priority, seeks opportunities to improve product/services

Physical, Mental, Environmental & Working Conditions

• Moderate amount of walking, sitting, and writing.
• Moderate to significant amount of stress in meeting deadlines and dealing with day-to-day events in the execution of job duties.
• Needs flexibility and adaptability to change.
• Candidate must be self-disciplined and a self-starter and able to work independently with a flexible work schedule.