Appeals and Grievances Coordinator (Fort Washington)

Req ID:108659NTT DATA Services strives to hire exceptional, innovative and passionate individuals who want to grow with us. If you want to be part of an inclusive, adaptable, and forward-thinking organization, apply now.We are currently seeking a Appeals and Grievances Coordinator to join our team in Fort Washington, Pennsylvania (US-PA), United States (US).System: the appeals system and the UM system is the same. They use JIVA. Will train on it. JOB DESCRIPTION:Appeals and Grievance Coordinator Job Description:This position is responsible for ensuring that complaints, grievances and appeals, presented by Plan members or their representative, and providers are resolved in accordance with established policies and procedures, the National Committee for Quality Assurance, and Federal/State guidelines. The Coordinator of Appeals and Grievances acts as a member advocate and independently communicates with Advocacy Groups, Community Representatives, Providers, Physicians, and all Plan departments including, but not limited to, Legal and Government Affairs, to interpret and enhance the understanding of policies and procedures for complaints, grievances and appealsMonitors to ensure that complaints, grievances and appeals presented by plan members are resolved in accordance with established policies and proceduresProcesses and adjudicates member and provider medical necessity disputes including member grievances, appeals, and requests for a hearingAdvises members on the application of benefits policies and the appeals process; including helping members understand the outcomes and implications of appeals decisionsAssists member or provider, or provider on behalf of the member, in filing a formal appeal and grievance.Identifies and investigates the reason for denial trends, reports findings to the appropriate entities and provides management with summary findings.Identifies deficiencies and develops corrective action plans to ensure compliance is metUpdates and generates authorizations for services that have been appealed, as well as communicates this information to various departmentsPrepares, develops and presents written case summaries for all adverse determination for the purpose of conducting State Fair HearingsCommunicates updates and status of outstanding member and provider complaints/issues to managementMaintains accurate, timely and complete record of appeals in the authorization systemMaintainsthe performance standard of processing 98% of all member first level appeals as defined in all regulatory and accreditation standards. E.g. 30 days from receipt of appeal for 1st level.Actively seeks the involvement of the legal department or government affairs, whenever necessary, for clarification and supporting documentation.Documents, in the appropriate system, all correspondence with a member and or a provider related to an appeal or grievance issue.Uses sound judgment and discretion when communicating findings related to an appeal. When necessary, will obtain authorization for release of sensitive and confidential information.Tracks and reports case turnaround time and follows up with the plan, when this requirement is not met.Responsible for communicating NCQA requirements to appropriate staff involved in the member appeal process.Keeps current with rules, regulations, policies and procedures relating to Plan member benefits, member's rights and responsibilities, and Complaints and Grievances.Follows up when compliance standards are not meet.Adheres to Plan policies and procedures and supports the mission and values of Plan.About NTT DATA ServicesNTT DATA Services is a global business and IT services provider specializing in digital, cloud and automation across a comprehensive portfolio of consulting, applications, infrastructure and business process services. We are part of the NTT family of companies, a partner to 85 % of the Fortune 100. NTT DATA Services is an equal opportunity employer and will consider all qualified applicants for employment without regard to race, gender, disability, age, veteran-status, sexual orientation, gender identity, or any other class protected by law.Posting Date:Department: -