Appeals and Grievance Specialist

Job Title

This position requires the ability to work independently researching and reviewing inquiries from members and providers that also requires knowledge of benefit interpretation, claims reviews, CPT and ICD coding. Bachelor's Degree and minimum 5 years of relevant experience.

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 Requirements.

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.

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 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 Plan organization in order to achieve member and provider satisfaction and/or operational effectiveness and efficiencies which contribute to maximum Medicare STAR ratings.