Appeals and Grievance Specialist

This position requires the ability to work independently, researching and reviewing inquiries from members and providers, and requires knowledge of benefit interpretation, claims reviews, CPT and ICD coding. A Bachelor's Degree and a minimum of 5 years of relevant experience are required. Requirements 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. Certify that providers and members are reimbursed accordingly using Medicare reimbursement policies and procedures. Responsibilities 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 . Coordinate with pertinent departments to effectuate resolution resulting from grievance and appeals resolution decisions made at the plan level or by independent review entities, adhering to policies and procedures based on regulated state and federal policies pertaining to the processing of grievances and appeals. Analyze grievance and appeals data and develop tracking and trending reports at prescribed frequencies to identify and communicate root causes of member and provider dissatisfaction. Recommend process improvements to pertinent departments within the Plan organization to achieve member and provider satisfaction and/or operational effectiveness and efficiencies that contribute to maximum Medicare STAR ratings. #J-18808-Ljbffr MDAEdge