Position Title: Member Appeals & Grievances Coordinator Assignment Duration: 3 months Work Arrangement: Remote Shift: Standard EST
Position Summary:
The Member Appeals and Grievances (A&G) Coordinator performs administrative functions associated with incoming Member Appeals and Grievances. The A&G Coordinator is responsible for identification, intake, and distribution of member appeals and grievances.
The A&G Coordinator maintains organized, secure, and efficient record keeping processes. The A&G Coordinator is responsible for responding to other business areas and members / providers regarding status of appeals and grievances or A&G processes in a timely and professional manner. The A&G Coordinator establishes and maintains collaborative and meaningful interdepartmental relationships.
Key Responsibilities:
Appropriate and compliant identification of appeals and grievances during intake. Accurate and detailed entry into the A&G system of record. Timely distribution of all appeals and grievances to the Appeals and Grievances Specialists in accordance with department rules and deadlines.
Responsible for data accuracy during entry into the A&G system of record to support the integrity of trend analysis and reporting and development/management of appropriate workflows to minimize manual errors and ensure compliance and consistency.
Responsible for identifying trends and/or areas of concern to be raised to the A&G Management team.
Assist the A&G Management team with audits and reporting needs as necessary and applicable.
Participation / creation of daily, weekly and / or monthly reports for the A&G Management team as part of the internal auditing and monitoring program. Reports include analysis and trend identification.
Participate in or lead training with the A&G Management team, A&G Specialists and / or new Coordinator staff. Includes maintenance of up-to-date materials related to the Coordinator role.
Meets all required deadlines for entry into the A&G system of record, responses to inquiries from other departments, return telephone calls / voicemails, etc.
Other appeals and grievances support duties as assigned.
Qualification & Experience:
Bachelor’s degree in Health Care Administration, related field, or an equivalent combination of education, training, and experience is required.
Microsoft Office Applications
Demonstrated ability to use proprietary healthcare management system(s)
Proven ability to identify problems and procedural irregularities, collect data, establish facts, and draw valid conclusions
JIVA
Facets
Express Scripts, Inc
HPMS
Access
2 or more years of experience in a healthcare setting, specifically related to Appeals and Grievances
Experience with data entry, trend analysis, and reporting
Experience with health insurance (Commercial, Medicaid and Medicare)
Experience with rules and regulations governing health insurance (Commercial, Medicaid and Medicare)
Experience communicating with a provider network
Certified Professional Coder (CPC) certification
Pre-employment background check
Excellent attention to detail and excellent organizational skills
Excellent oral, written and interpersonal communication skills required
Ability to be flexible and work independently, as well as collaborate with other departments across the organization
Ability to work effectively in a fast paced environment
Problem solving
Ability to abstract data, analyze and identify trends
Ability to multi task
Ability to provide high quality customer service
Regular and reliable attendance is an essential function of the position.
Flexibility to work some evening / weekend hours if necessary
Work is normally performed in a typical interior/office work environment.
No or very limited physical effort required. No or very limited exposure to physical risk.
Applicant Notices & Disclaimers
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At SPECTRAFORCE, we are committed to maintaining a workplace that ensures fair compensation and wage transparency in adherence with all applicable state and local laws.This position's pay range is $26.00/hr - $27.30/hr.
