Coordinator

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Please see below. If that is you then make sure to customize your resume (employers want to know how your experience matches their hiring requirements as shown on the job summary below). Use bullet points that show your experience and qualifications then email the custom resume to Thomas Lepera at [email protected]. Job postings at this company open and close quickly so send him your **custom email ASAP. For qualified candidates, Tom will provide the company's application link for the role to apply, and will follow up with his company contact on your behalf. Keep salary blank when you apply. ** Coordinator Appeals & Grievances Remote Job * Education/ Experience: *

• Required High School/GED
• Required a minimum of two (2) years' work experience in a Managed Care environment
• 1 to 3 years' experience in grievance/appeals environment required

Responsibilities:

Reporting to the Supervisor, Appeals and Grievances, this position is responsible for the administrative tasks for coordination of member and/or provider appeals, the analysis of claims and appeals, and the review of medical management authorizations.

• Research and Investigate member and/or provider appeals and grievance requests, including review of UM/claim denial reasons, contract/regulatory rules, benefits, and documentation received on appeal/grievance
• Distribute meeting materials, reports, and follow-up documentation as needed.
• Facilitate, Manage, and guide panel meetings (i.e., telephonic, video conference and in-person) by enforcing guidelines, fostering order and engagement, and ensuring smooth and cohesive discussion.
• Communicate effectively with panel members, stakeholders, and leadership to ensure alignment and clarity of appeal(s).
• Maintain confidentiality, organization, and integrity in handling sensitive information.
• Upload recording, documentation, and transcription to capture key discussions and decisions.
• Outreach call(s) made to members/participants, providers and /or member/participant representatives, to acknowledge receipt of appeal/grievance and discuss intent of appeal/grievance
• Explain the appeal/grievance process including helping members understand the outcome and implication of appeals decisions
• Prepares case file (original denial, all information received on appeal, medical records, etc.)
• Schedule participant/member for committee panel sends scheduling letter if needed
• Prepares, develops and presents written case summaries, if needed and process dictates, for all adverse determination for the purpose of conducting State Fair Hearings
• Prepare and send cases files to other teams as needed (e.g. legal, external appeals, state fair hearings, etc.)
• Communicates updates and status of outstanding member and provider complaints/issues to management
• Monitors to ensure that all problems with appeals/grievances presented by plan members/participants are resolved in accordance with established policies and procedures
• Update and/or generate authorization updates requests, for services that have been appealed
• Maintains accurate, timely, and complete record of appeals and grievances in the appeals system and documents, all correspondence with a member/participant, representative and/or a provider, related to an appeal or grievance issue
• Maintains quality and compliance standards as dictated by the state and federal entities
• Maintains contractual agreements with participating providers related to appeals and grievances
• Monitors caseload daily to ensure all cases are kept within compliance; follows up and escalates when compliance standards are at risk
• Actively seeks the involvement of the legal department or compliance department, as necessary, for clarification and supporting documentation by escalating issues to appeals and grievances management
• Obtain authorization for release of sensitive and confidential information
• Keeps current with rules, regulations, policies and procedures relating to Plan member benefits, member's rights and responsibilities, and Complaints and Grievances
• Ensure case file is sent to appropriate committee for decision making or example, internal committee/panel, independent review organization, internal medical director - as process dictates
• Provide support presenting cases and facilitating committee meetings as needed
• Send appeal to an independent review organization portal, for those appeals that require an external match specialty review
• Obtain data from multiple systems/vendors to ensure all documentation needed for appeal is obtained, for e.g. PerformRX, LTSS and other systems/vendors as needed
• Collaboration with internal counterparts as needed to ensure proper handling of the appeal e.g. UM team, medical directors, claims, contact center, vendors as needed (e.g. PerformRX)
• Creates decision letter with detail description of the nature of appeal / grievance including rational for the decision and options for moving forward
• Initiate and follow up on effectuations (um authorization update/claim adjustment) for overturned appeals/grievances

*Education/ Experience: *

• Required High School/GED
• Required a minimum of two (2) years' work experience in a Managed Care environment
• 1 to 3 years' experience in grievance/appeals environment required

The Ideal Person will have:

• Proven experience as a facilitator or moderator /similar
• Experience organizing and managing meetings.
• Excellent verbal and written communication skills
• Ability to engage and manage diverse groups.
• Awareness and sensitivity to diverse cultural backgrounds
• Ability to create a positive environment.
• Ability to handle challenging situations and conflict constructively.
• Familiarity with presentation software, video conferencing tools ( Zoom & Team) and relevant technology
• Proficiency with Windows and Microsoft Office applications, including Excel, Access, PowerPoint and Outlook
• Knowledge of the basic health care industry, managed care principles, claims, and medical terminology
• Ability to work collaboratively or independently; deliver high-quality work; attention to detail and flexibility; excellent verbal and written communication skills communication skills

Our Comprehensive Benefits Package

Flexible work solutions including remote options, hybrid work schedules, Competitive pay, Paid time off including holidays and volunteer events, Health insurance coverage for you and your dependents on Day 1, 401(k) Tuition reimbursement and more.

Your career starts now. We are looking for the next generation of healthcare leaders.

At AmeriHealth Caritas, we are passionate about helping people get care, stay well, and build healthy communities. As one of the nation's leaders in healthcare solutions, we offer our associates the opportunity to impact the lives of millions of peop