Contractual Reviewer-Senior

Independent Health Association•Buffalo, NY

1d•Onsite

About The Position

The Contractual Reviewer-Senior will be responsible for providing an organized, timely and consistent review and investigation of provider and/or member complaints and/or appeals. The Contractual Reviewer-Senior will be required to rely on their ability to synthesize a great deal of information in the interest of effectively understanding the matter at hand to, in turn, determine the steps that need to be taken to resolve the issue. The individual will frequently be called upon to collaborate with multiple departments and associates to properly investigate appeals/complaints. The Contractual Reviewer-Senior will also be responsible for providing member education/outreach related to coverage determinations and member benefit contract information.

Requirements

High school diploma or GED required.
Three (3) years of experience in a member or provider focused position required.
Ability to understand and articulate complex issues, systems, process and/or concepts with minimal assistance from management required.
Ability to analyze problems systematically, organize information, identify underlying causes and generate solutions while recognizing the impact on stakeholders and the organization.
Excellent verbal, written and interpersonal communication skills required.
Ability to handle escalated calls and to deliver messages clearly and articulately regarding decisions.
Possess initiative, attention to detail, and solid, logical thinking capabilities.
Proven ability to manage multiple, time-sensitive priorities and adherence to all deadlines, while remaining organized in a fast paced, ever-changing environment.
Proven examples of displaying the IH values: Passionate, Caring, Respectful, Trustworthy, Collaborative and Accountable.

Nice To Haves

Associates degree preferred.
Experience with healthcare benefits, contracts, and medical terminology preferred.

Responsibilities

Research, investigate, and resolve all levels of complaints/appeals independently.
Review Independent Health policies, contracts, clinical documentation, claims systems, pharmacy formularies, procedures, and department directives.
Collaborate with internal and external resources to resolve complaints/appeals.
Manage individual workload to adhere to regulatory timeframes, especially in consideration of upcoming absences.
Research, investigate, and make decisions regarding appeals and complaints in accordance with established guidelines, regulations, and member contracts.
Ensure compliance with timeframes for handling appeals/complaints.
Ensure verbal and written responses to complaints/grievances, appeals, and investigations follow regulatory standards.
Provide member education/outreach related to coverage determinations and member benefit contracts.
Identify appeal trends and process improvements.
Document all appeal/complaint activity thoroughly and accurately, creating a detailed summary of findings.
Monitor daily reports to ensure accuracy and timeliness of complaints/grievances and appeals.
Assist in developing systems, workflows, and coverage criteria to better meet customer needs.
Coordinate and collaborate with ancillary departments and peers within the contractual team to render consistent coverage determinations and claims payments.
Demonstrate positive interrelationships and service excellence.
Coordinate with external agencies to prepare case files for external appeals when needed.
Assist in meeting department goals and objectives.
Identify process improvements to continuously improve member/provider satisfaction.
Attend assigned meetings as a department representative and report to team members when necessary.