Appeals and Grievance Specialist II - Health Plan Admin

Summary:

This position requires the ability to work independently researching and reviewing inquiries from members and providers. Also requires knowledge of benefit interpretation, claims reviews, CPT and ICD coding. Responsible for reviewing, classifying, researching and resolving member complaints (grievances and/or appeals) and communicating resolution to members or their authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid Services and TRICARE. Coordinates with pertinent departments to effectuate resolution resulting from grievance and appeals resolution decisions made at the plan level or by independent review entities. Adheres to CHRISTUS Health Plan policies and procedures which are based on regulated state and federal policies pertaining to the processing of grievances and appeals. Analyzes grievance and appeals data and develops tracking and trending reports at prescribed frequencies for the explicit purpose of identifying and communicating trended root causes of member and provider dissatisfaction. Recommends process improvements to pertinent departments within the CHRISTUS Health Plan organization in order to achieve member and provider satisfaction and/or operational effectiveness and efficiencies which contribute to maximum Medicare STAR ratings.

Responsibilities:

• Research and provide resolution to issues such as claim denials, member and provider complaints, and reconsideration and redetermination requests
• Review and respond to complaints, grievances and appeals within the stated time frame for each request
• Ensure 95% compliance with the Center for Medicare and Medicaid Services (CMS) guidelines is met by adhering to all state and federal regulations
• Analyze and resolve customer inquiries by adhering to CMS guidelines and CHRISTUS Health internal policies and procedures
• Actively communicate with other associates to guarantee accurate and timely responses to inquiries involving internal/external customer needs
• Be proactive in educating members, providers and others about CHRISTUS Health plans appeal/grievance process, plan terminations, contract terminations and benefit summary
• Certify that providers and members are reimbursed accordingly using Medicare reimbursement policies and procedures

Requirements:

Work Type:

Full Time