Appeals & Grievances Coordinator

Location: Orange, CA
Date Posted: 04-10-2018
Appeals & Grievances Coordinator – Managed Care
Orange, CA
*** This is a Full-Time, Benefits Available, CONTRACT assignment, expected to last around 5-6 months, or longer! ***
Your Job Summary:
The Quality Improvement Appeals & Grievances Coordinator assists with specific aspects of the Quality Management Program, including the denials, appeals, and grievances process. The Coordinator supports the organization by administratively assisting to resolve provider payment disputes. The Coordinator is responsible for supporting clinical staff in the execution of the grievance and appeals process, which includes coordinating the investigation among departments, collaborating with staff to develop corrective action plans, and monitoring corrective action taken. Facilitates the consolidation of the complaints and grievance activities on a quarterly basis, and prepares monthly, quarterly and annual reports on assigned quality improvement activities.
Your Background:
Requires an education level of at least an Associate’s or Bachelor’s degree; additional years of experience will be considered.
Requires exceptional phone / customer service skills, as well as very strong computer user skills.
At least 2-3 years’ experience in a medical office, hospital or health plan call center, or other healthcare support role with heavy computer & phone use.
Requires 2-3 years of claims, contracting, or related experience, at a Managed Care Organization (Health Plan, IPA/Medical Group, HMO, TPA/MSO, etc).
Prefer around 1-2 years of direct experience handling Denials & Grievances & Appeals.
Requires basic to intermediary familiarity with Medical terminology (1-3 years direct experience).
Direct experience with guidelines for Medicaid/Medicare and related state programs is required.
Must have strong skills in medical assessment / medical record review; knowledge of coding a plus.
Experience using Milliman or InterQual criteria for medical necessity, setting and level of care, and concurrent patient management.
Computer skills to include Microsoft Word, Excel, database use, and basic data entry.
Your Duties:
  • Screens and prioritizes incoming denials, appeals, and grievances.
  • Supports clinical staff (nurses, physicians, etc) involved in the denials, appeals, and grievances process.
  • Processes incoming requests, including forwarding case files and supporting documentation, based on established guidelines.
  • Forwards denials, appeals, and grievances requests that require clinical judgment to department Nurses, the Manager, or Medical Director.
  • Maintains a full caseload while meeting or exceeding designated metrics and turn-around timeframes.
  • Answers inbound calls from providers and other departments, verifies status of all denials, appeals, and grievances, and enters the information necessary to complete the caller’s request into the designated database.
  • Informs providers of the decision on their requests, per department procedure.
  • Assists with the resolution of escalated member or provider inquiries related to denials, appeals, and grievances.
  • Serves as subject matter expert for members, providers, and internal departments to promote an understanding of the denial, appeal, and grievance requirements and processes.

CareNational Healthcare Services
623.201.8732 (CALL – TEXT – FAX)
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