Grievance & Appeals - Grievance & Appeals Coordinator 201-1008

CommunityCare•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 federal, state, and accreditation regulations. The coordinator receives and responds to written and oral complaints and requests from members and providers, maintains complete case documentation, and enters accurate information into the grievance and appeals electronic tracking system (GATS). The position works with internal departments, members, providers, attorneys, CMS, and MAXIMUS Federal Services as needed to resolve issues and administer the appeals process. The coordinator communicates decisions in writing, helps coordinate authorizations and claim payments when indicated, prepares files for audits, and assists the Supervisor with special projects and CMS quarterly reports. The work may involve members who are disgruntled or upset.

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.
Highly organized and attentive 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 federal, state, and accreditation requirements.
Receive and respond to written and oral member and provider complaints and requests according to CommunityCare procedures.
Maintain appropriate file documentation showing the steps taken in the process.
Coordinate with Medical Management, Member Services, Claims, Pharmacy, Provider Services, Senior Management, members, providers, and member representatives as needed to resolve issues.
Interact with CMS and MAXIMUS Federal Services when indicated.
Ensure each case is entered accurately and completely in the grievance and appeals electronic tracking system (GATS).
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.
For inquiries forwarded from the Department of Insurance, meet specified communication and timeframe requirements and document accordingly.
Perform other job-related duties as assigned.