Appeal & Grievance Intake Coordinator - Hybrid

Blue Cross Blue Shield of Arizona•Phoenix, AZ

7d•Hybrid

About The Position

Awarded a Healthiest Employer, Blue Cross Blue Shield of Arizona aims to fulfill its mission to inspire health and make it easy. AZ Blue offers a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions. At AZ Blue, we have a hybrid workforce strategy, called Workability, that offers flexibility with how and where employees work. Our positions are classified as hybrid, onsite or remote. While the majority of our employees are hybrid, the following classifications drive our current minimum onsite requirements: Hybrid People Leaders: must reside in AZ, required to be onsite at least twice per week Hybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per week Hybrid 2 (Operational Roles such as but not limited to: Customer Service, Claims Processors, and Correspondence positions): must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per month Onsite: daily onsite requirement based on the essential functions of the job Remote: not held to onsite requirements, however, leadership can request presence onsite for business reasons including but not limited to staff meetings, one-on-ones, training, and team building Please note that onsite requirements may change in the future, based on business need, and job responsibilities. Most employees should expect onsite requirements and at a minimum of once per week. This position is hybrid within the state of AZ only. This hybrid work opportunity requires residency, and work to be performed, within the State of Arizona. PURPOSE OF THE JOB Performs triage (intake, classification, case file setup and assignment) of Medicare Part C and D grievances and appeals; provides administrative, clerical, and other related support to the Grievance and Appeals (G&A) staff; establishes, maintains, and monitors grievance and appeal workload tracking and workflow processes; assists with maintaining regulatory compliance, timeliness requirements and ensuring accuracy standards are met; completes day-to-day operational tasks assigned according to defined processes and procedures; prepares G&A case file folders and assists with tracking and maintaining G&A case records and files; and assists with collecting and reporting G&A related performance and regulatory data.

Requirements

2 years of experience in a Medicare Advantage (Part C) and Prescription Drug Benefit (Part D) insurance plan and/or other managed care organization.
High school diploma or GED in general field of study.
Math, communications and business skills normally demonstrated by a high school degree or equivalent.
Intermediate PC user, including Microsoft Word, Excel, Outlook, Power Point, and Adobe Acrobat Pro.
Intermediate skill using office equipment, including copiers, fax machines, scanners and telephones.
Maintain confidentiality and privacy as outlined by HIPAA.
Strong critical thinking skills.
Must possess highly developed interpersonal skills and communications skills, with a strong customer service orientation, and practice interpersonal and active listening skills to achieve customer satisfaction.
Compose a variety of business correspondence
Interpret and translate policies, procedures, programs and guidelines
Strong investigative and analytical research skills
Navigate, gather, input and maintain data records in multiple system applications
Follow and accept instruction and direction
Establish and maintain working relationships in a collaborative team environment
Organizational skills with the ability to prioritize tasks and work with multiple priorities

Nice To Haves

2 years of additional experience, including working knowledge of CMS Managed Care Manual Chapter 13 - Beneficiary Grievances, Organization Determinations, and Appeals and CMS Prescription Drug Benefit Manual Chapter 18 - Part D Enrollee Grievances, Coverage Determinations, and Appeals, knowledge of healthcare billing and claims adjudication processes

Responsibilities

Receive, sort, classify, prioritize, manage, and distribute inbound G&A mail, fax, inter-office, and other correspondence according to policies and procedures, the CMS Managed Care and Prescription Drug Benefit Manuals, and other regulatory and procedural rules, guidelines and timeframes.
Prepare and assign individual case files to the appropriate G&A staff, continuously update tracking logs, databases, and reports, monitor and manage case status, timelines, statistics, regulatory compliance and performance as required.
Prepare and mail, fax, inter-office, and other outbound correspondence.
Coordinate with enrolled members and providers submitting grievances and appeals to obtain additional information or clarification as required.
Coordinate case files with G&A Staff (administrative evaluation of timely filing, claim payments, insufficient information, etc.), Quality Management staff (quality of care issues) Medical Directors (clinical evaluation of covered services, appropriate level of care, medical necessity, quality of care, etc.) and/or the Chief Medical Officer (clinical evaluation of covered services, appropriate level of care, medical necessity, quality of care, etc.) as required.
Assist in the preparation and submission of cases to the Independent Review Entity (IRE), as required.
Receive and coordinate Administrative Law Judge (ALJ), Medicare Appeals Council (MAC), and Federal District Court cases with the G&A staff, Medical Director, Legal, and other departments as required.
Provide information regarding rights and responsibilities to enrolled members, providers, and other QHP departments as outlined in the Medicare Managed Care Manual.
Meeting and exceeding the published department production standards.
Meeting and exceeding the published department quality standards.
Full use and knowledge of all research tools (Processing Manual, Meeting Minutes, Department Memos, and Training Material).
Maintain awareness of legislation, CMS website/instructions that impact Grievance and Appeals
Be a positive influence on the team culture
Actively participate in Team meetings, vocalizing opportunities for process improvement and team knowledge share.
Identify substandard performance by automated processes or software applications
Actively seeks out opportunities to help others
Work independently, demonstrating resilience in overcoming obstacles and barriers
Obtain mastery in all workflows identified in Level 1 and support in the day-to-day operation of Grievance & Appeals
Periodically develop and lead content during Team meetings
Ability to train, display coaching skills
Troubleshoot any issues with requestor to achieve ultimate efficiency and desired output
Identify, document, and take ownership over identified automated process or software application issues. Submitted Serving Blue tickets and assisting the assigned technician with troubleshooting problems until the issue is resolved
Active participant in all regulatory audits
Be known as a SME in your Functional Unit
Coverage for individuals or areas of need within the Department
Provide Quality Assurance of others’ work, provide feedback in a meaningful and constructive way.
Obtain proficiency in Microsoft Office
Develop and maintain relationships with internal customers, colleagues and supply vendors for optimum business partnering results
Assumed leadership role in Functional Unit audits
Prioritize work to manage multiple priorities during peak times
Leadership role with stakeholders and customers
Advanced skill with operational process flows and associated technology
Manage inventory and expected business SLAs
Actively seeks out special projects for Leadership experience
Ownership and accountability of timely response to regulatory inquiries