Appeals and Grievance Coordinator

Presbyterian Healthcare Services

1d•Onsite

About The Position

Build your Career. Make a Difference. Presbyterian is hiring a skilled Appeals and Grievance Coordinator to join our team. This is a full-time, exempt position based at the Reverend Hugh Cooper Administrative Center. The work shift is during the day.

Requirements

High School Diploma or GED
Five years customer service experience required.
Three years experience in health care or insurance setting, of which one year must have been in interpretation of regulations for complaint, grievance or appeal processing.

Nice To Haves

Bachelors degree preferred in healthcare related field.
Preferred experience in claims processing, patient financial services, utilization management, in a in an HMO/MCO/MSO or health insurance environment

Responsibilities

Responsible for the daily coordination of activities within the Appeals & Grievance Department.
Assists in assuring that all compliance timelines are met.
Acts as a mentor, a resource as well as a team lead in addressing complaints and appeals/grievances.
Interacts with regulatory agencies, patients, members, stakeholder, leaders, and internal departments and staff.
Function as primary contact for various regulatory bodies who maintain oversight of the administration of complaints, appeals, and grievances.
Provides feedback and process improvement recommendations to appropriate quality committees based on analysis and trending of complaint data and appeal/grievance data.
Responsible for identification of trends and meeting goals.
Coordinates daily activities of the Specialists providing growth opportunities and mentoring to each team member.
Responsible for oversight of work production of Specialists, and review of decisions made by Specialists.
Escalates appropriate issues for further involvement.
Coordinates, investigates, and resolves customer complaints and appeals/grievances.
Independently identifies issues needing resolution.
Responsible for making decisions in cases of dispute that were not decided or resolved.
Responsible for reviewing research and decisions by other business units, organizational department heads, and other departments and conducting more detailed investigative research into the matter, meet as required in order to achieve the best outcome for the complainant, grievant/appellant while best representing the interests of Presbyterian.
Works closely with Legal/Risk Management, Medical Directors, Medical Staff, department leads, department Directors, regulatory representatives, and outside professional consultants to achieve consistent outcomes in cases of complaints, appeals and grievances.
Assists in maintaining compliance with all applicable compliance standards, meeting goals relating to customer and provider satisfaction and providing excellent levels of service to all internal and external customers.
Functions as primary contact for various regulatory bodies who maintain oversight of the administration appeals and grievances.
Required to compose correspondence to all regulatory agencies in compliant format, to include corrective action plans, follow up on cases, and reports as requested by regulators.
Will attend and represent the organization at meetings with regulators as the need arises.
Required to communicate in writing with customers or their representatives, health plan members, providers or their designated representative.
Responsible for application of contract language from contracts in correspondence.
Ensure written correspondence is reviewed for regulatory statutes and requirements for a multitude of customer types and product line specified requirements.
Ensure responses to complainants and grievant are within policy timelines as defined by the appropriate regulatory body.