Appeals & Grievance Coordinator

AllCare Health•Grants Pass, OR

9h•$23 - $25•Onsite

About The Position

The Appeals & Grievance Coordinator in AllCare Health’s Quality department processes and resolves Oregon Health Plan and Advantage Health Plan member and provider appeals and grievances. The role investigates complex complaints involving enrollment and claims, provider payment disputes, medical appeals, and reversals. It prepares complete case files for the medical director, coordinates care or payment of services, forwards appeals to CMS Independent Review Entity or DMAP for further review, and collaborates with DMAP, CMS, or the independent review entity. The position is based onsite in Grants Pass, Oregon. The schedule is Monday through Friday, 8:00 a.m. to 5:00 p.m., with a one-hour unpaid lunch and two paid 15-minute breaks, for 40 hours per week. Local travel using a personal vehicle may be required, subject to mileage reimbursement.

Requirements

Associate's degree from a two-year college or university; or one to two years of related experience and/or training; or an equivalent combination of education and experience.
May be required to use a personal vehicle for local travel; mileage is subject to reimbursement.
Must be able to work onsite for all scheduled shifts.
Must occasionally lift or move up to 10 pounds and meet the physical demands described in the posting.

Nice To Haves

Certified Professional Coder (CPC) certification is strongly preferred.

Responsibilities

Investigate and resolve complex member and provider complaints related to enrollment and claims, provider payment disputes, medical appeals, and reversals within the health care industry.
Provide the medical director with a complete case file for processing appeals and grievances.
Coordinate care or payment of services.
Forward appeals to CMS Independent Review Entity or DMAP for further review.
Collaborate with DMAP, CMS, or the independent review entity for review.