Job Description: Respond to written/verbal grievances, complaints, appeals and disputes submitted by members and providers: Review, analyze, research, resolve and respond to all types, in accordance with guidelines established by the Centers for Medicare and Medicaid Responsibilities:
Review and evaluate appeal and grievance requests to identify and classify member and provider appeals; process member and provider appeals and complaints as appropriate to meet the CMS, State and Accreditation requirements.
Determine eligibility, benefits, and prior activity related to the claims, payment or service in question.
Review research performed by operational areas to ensure the appropriate resolution to the appeal/grievance has been achieved: review contracts, member materials, medical payment policies, and Provider education documents in researching and deciding the outcome of appeals.
Accountable for appropriate review and determination in compliance with state and federal regulations and NCQA.
After review, determine if a denied service or claim should be reversed; or consult with the Medical Director to complete a final determination. Delegate physician review as appropriate to Medical Director or Independent Review Organization(s).
Conduct thorough investigations of all member and provider correspondence by analyzing all the issues involved and obtaining responses and information from internal and external entities.
Perform comprehensive research related to the facts and circumstances of a member complaint, to include appropriate classification as a grievance, appeal, or both, in accordance with regulatory requirements.
Research appeal files for completeness and accuracy and investigate deficiencies. Consult with internal areas as required (such as the Legal Department) to clarify legal ramifications around complex appeals.
Adjudicate claims in accordance with the most current policy benefits, limitations or exclusions and claims policies and procedures.
Provide written acknowledgment of member and provider correspondence; prepare written responses to all member and provider correspondence that appropriately address each complainant’s issues and are structurally accurate.
Follow-up with responsible departments and delegated entities to ensure compliance.
Responsible for making verbal contact with the member or authorized representative during the research process to further clarify, as needed, the member's complaint.
Ensure documentation requirements are met: create and document service requests to track and resolve issues; document final resolutions along with all required data to facilitate accurate reporting, tracking and trending.
Provide all follow up documentation of outcome to practitioners, providers, and members.
Responsible for the timely, complete, accurate documentation of the appeal and/or grievance both electronically and in hard copy; and for timely and accurate written documentation to the member and/or provider advising of the resolution of the appeal and/or grievance.
Prepare cases for medical and administrative review detailing the findings of their investigation for consideration in the plan’s determination; case summaries for appeal resolution notification; and send completed cases for scanning.
Responsible for ensuring appeals case files are accurately prepared and submitted to the IRE within 24 hours of the decision to uphold the initial denial for expedited appeals, and not later than 30 calendar days after the receipt of a standard pre-service appeal and 60 calendar days after the receipt of a claim appeal.
Enter and maintain critical data and records in support of business requirements, regulatory obligations timeframes and NCQA standards.
Ensure daily production log and team database is maintained; manage database for physician review appeals in support of business requirements, regulatory obligations and NCQA; monitor daily and weekly pending reports and personal worklists, ensuring internal and regulatory timeframes are met.
Enter and maintain critical data and records in support of business requirements, regulatory timeframes, and NCQA standards, into the appropriate systems.
Track and trend outcomes; and analyze data to provide reporting as required for UM, QA, etc., and to identify provider education opportunities.
Responsible for monitoring the effectuation of all resolution/outcomes resulting from the appeals, Administrative Law Judge, and Medicare Appeals Council processes.
Identify areas of potential improvement and provide feedback and recommendations to management on issue resolution, quality improvement, network contracting, policies and procedures, administrative costs, cost saving opportunities, best practices, and performance issues.
Serve as liaison departments, delegated entities, medical groups and network physicians to ensure timely resolution of cases; collaborate and partner with internal departments for resolution and education; work with physicians, hospitals and internal staff to gather information needed to resolve complex claim issues
Perform other tasks, projects, etc., as needed or directed.
Associates Degree; Bachelors’ preferred
2 – 3+ years of related, professional work experience required
2 years’ experience in Medicare Managed Care preferred
Experience in a managed care/compliance environment preferred
Knowledge of medical terminology, provider reimbursement, medical coding, coordination of benefits and all types of medical claims required
Solid understanding of member and provider rights and responsibilities, particularly with appeals and grievances required
Familiarity with managed care state and federal regulations required
Prior auditing experience preferred
Customer service experience preferred
Proficiency in MS Office (word processing, and database/spreadsheet) required