Under the direction of the Customer Service Manager, this position is accountable for the comprehensive review, research and resolution of appeals and grievances submitted by both members and providers. This position is required to apply analytical and critical thinking when reviewing contract language, benefits and covered services in researching and providing an accurate and appropriate resolution in accordance with the Centers for Medicare and Medicaid Services (CMS) and the state of Nevada Division of Insurance. The appeal and/or grievance can include, but is not limited to customer service, claims, referrals, eligibility and benefit issues. This position is also responsible for compilation of such data as needed to identify areas for improvement, as well as keeping abreast of departmental issues and the need for revised/additional policies and procedures that will assist in the resolution of the appeal and/or grievance.
Nature and Scope:
The Appeals and Grievance Coordinator must be able to identify complex problems and provide a resolution as it pertains to appeals and grievances.
This position will be responsible to keep overall service issues in mind while resolving individual cases. It will be their responsibility to keep management informed of the customers opinions and viewpoints relative to claims and service in general. They will be called upon to identify themes and/or trends related to service and recommend solutions to these issues.
This position will participate in the development of Standard Work to improve the quality and service to our customers. In this process, they must utilize and apply Transformations Healthcare tools and principles.
This position must refer matters that involve problems that can develop negatively towards Hometown Health or matters affecting the departments operating and capital budgets directly to Leadership.
This position has contact with all Hometown Health departments, members, employers, brokers and providers and high standards of courteousness, performance, diplomacy and respect for confidentiality are essential.
This position has access to clinical staff for clinical related questions or issues. Licensed health professionals are on site as well as available via telephone and email.
The Appeals and Grievance Coordinator should exhibit the following traits:
╖ Strong customer service skills with the ability to provide service recovery immediately as needed.
╖ Working knowledge of CMS regulations as they relate to a Medicare Advantage Plan.
╖ Working knowledge of group, self-funded, individual and family and Medicare Supplement health insurance plans.
╖ Working knowledge of medical billing practices to include, but not limited to medical terminology, CPT, ICD9/10, and HCPCS coding.
╖ The ability to communicate professionally and diplomatically, clearly and concisely, both verbally and in writing.
╖ The ability to maintain confidentiality of medical and personal information of all customers.
╖ The ability to ensure all goals and deadlines are met.
╖ Demonstrated skills in problem identification, problem solving and process improvement.
Under no circumstances shall non-clinical appeal and grievance staff perform any activities related to the appeal and grievance management process other than:
╖ Performance of review of service request for completeness of information
╖ Collection and transfer of non-clinical data. Such data may include demographic information, employer name, insurance information, date of surgery, physician name, facility name, etc.
╖ Acquisition of structured clinical data in the form of medical records requests
╖ Activities that do not require evaluation or interpretation of clinical information
This position does not provide patient care.
The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.
Minimum Qualifications: Requirements – Required and/or Preferred
Must have working-level knowledge of the English language, including reading, writing and speaking English. Bachelors degree an accredited college or university. (Equivalent experience may substitute for education on a one year experience to one year education basis).
Two years experience in customer service or claims adjudication within the health care or health plan environment.
Certified Coding Specialist is preferred.
Computer / Typing:
Must be proficient with Microsoft Office Suite, including Outlook, PowerPoint, Excel and Word and have the ability to use the computer to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.