Grievance & Appeals - Grievance & Appeals Coordinator 201-1000

CommunityCare•Tulsa, OK

22h

About The Position

Responsible for all written inquiries from members seeking resolution through the grievance and appeals process. This role involves researching member issues, preparing documentation for each level of the appeal process, and ensuring adherence to established timeframes and regulatory compliance. The coordinator will respond to member and provider complaints, interact with various internal departments and external entities, and maintain accurate records in the grievance and appeals electronic tracking system (GATS). Additionally, the role includes notifying members of appeal decisions, coordinating claim processing, preparing files for audits, and assisting with special projects and reports. Explaining policies, procedures, and benefits related to the grievance and appeals process is also a key function. The work may involve dealing with disgruntled members.

Requirements

Customer service experience in managed care, insurance or healthcare environment required.
Successful completion of Health Care Sanctions background check.
Possess strong oral and written communication skills.
Ability to work on multiple tasks.
Proficient in Microsoft applications.
Highly organized and attentive to detail.
High school diploma or equivalent PLUS 5 years related experience OR Associates degree plus 1 year of related experience required.
Related experience consists of customer service, member service or claims processing in an insurance environment.

Nice To Haves

Managed care experience preferred.

Responsibilities

Researches member issues and prepares grievance and appeals information for each level of the appeal process.
Adheres to established grievance and appeals timeframes.
Assures compliance with Federal, State and Accreditation regulations.
Receives and responds to member and/or provider written and oral complaints and requests in accordance with CommunityCare's grievance and appeals procedures.
Ensures appropriate file documentation that demonstrate process steps.
Interacts with Medical Management, Member Services, Claims, Pharmacy, Provider Services as well as Senior Management to resolve issues.
Interacts with members, providers, and attorneys who represent the member regarding the grievance and appeals process.
Interacts with Center for Medicare and Medicaid Services (CMS) and MAXIMUS Federal Services as indicated.
Ensures the grievance and appeals electronic tracking system (GATS) is populated correctly and completely for each case.
Participates in the audit process.
Notifies members and/or providers in writing of the decision made at each level of the appeal process.
Coordinates with the Claims, Pharmacy helpdesk and or Medical Management to ensure that authorization is obtained and claim payment is processed, if indicated.
Prepares grievance and appeal files for audit.
Assist Supervisor with special projects and CMS quarterly reports as it relates to Grievance and Appeals.
Explains policies, procedures, available benefits and service options to members and/or providers related to the grievance and appeals process.
For inquiries forwarded from the Department of Insurance, adheres to all specified communication and timeframe requirements.
Documents accordingly in the file.
Perform other job-related duties as assigned.