Appeals & Grievance Coordinator

AllCare Management Services•Grants Pass, OR

1d•$23 - $25•Onsite

About The Position

This position is responsible for processing and resolving the Oregon Health Plan and Advantage Health Plan members and provider appeals and grievances by performing the following duties.

Requirements

All relevant experience can be listed in your resume to perform essential duties of the position including the following: lived, volunteer, professional, or a combination of experience and education.
May require the use of personal vehicle for local travel (subject to mileage reimbursement).
Associate's degree (AA) from a two-year college or university; or one to two years related experience and/or training; or equivalent combination of education and experience.
The employee must be able to work on-site for all scheduled shifts.

Nice To Haves

Certified Professional Coder (CPC) is strongly preferred.

Responsibilities

Investigates and resolves complex member and provider complaints related to enrollment and claims, provider payment disputes, medical appeals, and reversals within the health care industry.
Provides the medical director with a complete case file for processing of the appeals and grievances and coordinates care or payment of services.
Forwards appeals to CMS Independent Review Entity or to DMAP for further review.
Collaborates with DMAP, CMS, or the independent review entity for review.