Grievance & Appeals - Grievance & Appeals Coordinator 201-1008

Community Care•Tulsa, OK

About The Position

The Grievance & Appeals Coordinator handles written inquiries from members seeking resolution through the grievance and appeals process. The role researches member issues, prepares case information for each appeal level, follows required timeframes, and ensures compliance with applicable federal, state, and accreditation regulations. The coordinator maintains complete case documentation and accurate electronic tracking records, communicates decisions to members and providers, and works with internal departments and external parties to resolve issues. The work may involve interacting with disgruntled or upset members.

Requirements

Customer service experience in a managed care, insurance, or healthcare environment.
Successful completion of a Health Care Sanctions background check.
Strong oral and written communication skills.
Ability to work on multiple tasks.
Proficiency in Microsoft applications.
Strong organizational skills and attention to detail.
High school diploma or equivalent plus 5 years of related experience, or an associate degree plus 1 year of related experience.
Related experience must consist of customer service, member service, or claims processing in an insurance environment.

Nice To Haves

Managed care experience preferred.

Responsibilities

Research member issues and prepare grievance and appeals information for each level of the appeal process.
Adhere to established grievance and appeals timeframes and applicable regulatory requirements.
Receive and respond to member and/or provider written and oral complaints and requests in accordance with CommunityCare procedures.
Ensure case files document the appropriate process steps and populate the grievance and appeals electronic tracking system (GATS) correctly and completely.
Coordinate with Medical Management, Member Services, Claims, Pharmacy, Provider Services, Senior Management, and other parties to resolve issues.
Interact with members, providers, and attorneys representing members about the grievance and appeals process, and interact with CMS and MAXIMUS Federal Services as indicated.
Participate in audits and prepare grievance and appeal files for audit.
Notify members and/or providers in writing of decisions at each level of the appeal process.
Coordinate with Claims, the Pharmacy helpdesk, and/or Medical Management to obtain authorization and process claim payment when indicated.
Assist the Supervisor with special projects and CMS quarterly reports related to Grievance and Appeals.
Explain policies, procedures, available benefits, and service options related to the grievance and appeals process.
Meet communication and timeframe requirements for inquiries forwarded from the Department of Insurance and document the work in the file.
Perform other job-related duties as assigned.