Appeals & Grievances Coordinator – Managed Care
*** This is a Full-Time, Benefits Available, CONTRACT assignment, expected to last around 5-6 months, or longer! ***
Appeals & Grievances Coordinator Job Summary:
Appeals & Grievances Coordinator Background
- 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.
- 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.