Temporary Coordinator remote - Appeals & Grievances - MediGold Health Plan

Trinity Health•Columbus, OH

16h•Remote

About The Position

The Appeals and Grievance Coordinator is responsible for the processing and resolution of appeals, grievances and disputes from members and providers. MediGold is a not-for-profit Medicare Advantage insurance plan serving seniors and other Medicare beneficiaries across the United States. The organization is dedicated to providing excellent customer service, cost-effective care, and exceptional healthcare coverage, relying on talented colleagues in a wide variety of professional roles including information technology, financial analysis, audit, and provider relations.

Requirements

Bachelor’s degree or an equivalent combination of education and experience.
Three years of customer service experience or appeals and grievance experience, preferably in managed care (health insurance) or another health care setting.
Strong written and verbal communication skills.
Ability to interpret and apply Federal law and regulatory requirements ensuring compliance with Medicare Managed care obligations.
Ability to educate staff members, providers and enrollees about the appeals and grievance process.
Familiarity with claims processing, coordination of benefits and use of claims processing system.
Ability to follow Federal guidelines from CMS and Ohio Department of Insurance (ODI) for appeal and grievance resolution processes and requirements.

Nice To Haves

Legal or regulatory background or experience
Demonstrated public speaker/educator

Responsibilities

Document all appeal requests or grievances upon receipt in the operating systems and routes cases to appropriate clinical personnel for review.
Obtain confidential medical records from providers offices utilizing secure methods.
Responsible for preparation of case files and review with clinical colleagues.
Screen all incoming grievances, appeals and provider claim dispute to ensure they are within compliance requirements of CMS guidelines and corporate policies.
Gather, analyze and report verbal and written member and provider complaints, grievances and appeals in accordance with Federal regulations and time constraints.
Conduct grievance and appeal investigations and provider claim dispute investigations through internal and external interviews, chart and contract audits, inspection, and interpretations of appropriate CMS guidance and policies.
Prepare background, case summary and case files with records for submission to the Independent Review Entity (IRE) and ensures that cases are compliant and required timeframes are met.
Obtain required documents and completely prepare cases for Appeals Committee (MAC) review, Administrative Law Judge (ALJ) Hearings.
Prepares and reviews data universes for the Centers for Medicare and Medicaid Services (CMS) audits.
Participates in regular monitoring efforts and reports trending and outliers to senior management.
Responsible for ensuring 5-Star (maximum) ratings from CMS for appeals and grievance related measures.
Maintain compliance of all regulatory requirements that apply to beneficiary protection areas of appeals and grievance.
All other duties as assigned.