Coordinator, Appeals

Kaiser Permanente • Atlanta, GA

98d

About The Position

An Appeals Coordinator is responsible for coordinating member appeals, grievances, and other case types on behalf of various regions. Regions are required under Federal and State regulations to have consistent and timely processes in place for reviewing, investigating, and responding to members requests and/or concerns. These requests often contain complex, confidential, and sensitive issues. The responsibility of this position is to ensure that all case types are carefully documented, thoroughly researched, and formally reviewed with decisions disseminated within timeframes established by the Region and/or by external regulators. The appeals and grievances processes represent an increasingly important aspect of the overall member, patient, and customer service/experience function of the organization.

Requirements

• Minimum three (3) years experience working within or on behalf of a healthcare organization or similar related organization.
• Minimum three (3) years experience demonstrating strong customer service skills through the use of professional, courteous, respectful and timely communications (both oral and written).
• Minimum two (2) years experience working within Member Relations, preferably with direct experience in processing grievances, complaints, and inquiries.

Nice To Haves

• Minimum two (2) years of experience with Kaiser Permanente, preferably with direct experience working within the areas of Member Services, Member Experience, or Claims Services.
• Prefers basic knowledge of healthcare management and delivery, including utilization management, as they relate to regulatory operations.
• Knowledge of Kaiser Permanente benefits and membership contract parameters strongly preferred.

Responsibilities

• Documents the receipt of appeals (and other various case types, including grievances) and begins timeline tracking to ensure responses are generated within the established timeframe.
• Thoroughly researches and investigates each request/issue, including determining what information is necessary for an accurate and thorough review.
• Uses knowledge and judgment to review, evaluate and summarize the information in a succinct and logical manner.
• Ensures that eligibility information and benefit levels of members are determined, and ascertains if special/additional appeal and/or grievance mechanisms apply.
• Responsible for understanding health plan operations, including but not limited to: Benefits, Grievances, Appeals, Authorizations, Referrals, Billings, and Claims.
• Consults with other departments and stakeholders, as necessary, ensuring departmental responses meet various regulatory and departmental timelines.
• Prepares and distributes electronic Case Summaries for review and presentation to various internal stakeholders.
• Prepares various pieces of written correspondence for distribution internally, as well as externally.
• Creates and maintains member cases within the METRS system of record, following departmental DLPs and SOPs.
• Responsible for managing individual case inventories while maintaining regulatory compliance with established SLAs.
• Prepares thoughtfully written professional responses to various stakeholders, including for External Review, as appropriate.

What This Job Offers

• Industry: Ambulatory Health Care Services
• Education Level: Bachelor's degree