The Appeals and Grievances (A&G) Coordinator is responsible for supporting the end-to-end A&G process, including the intake, tracking, and resolution of member and provider complaints and appeals.
Requirements
- Supporting and participating in process improvements, system enhancement testing, new process implementations and documenting adjustments as requested.
- Maintaining appeal and grievance data through tracking mechanisms and processing case requests as necessary to support regulatory, internal or external requirements including audits.
- Performing administrative duties to track, organize, monitor and follow-up on case work with duties including, but not limited to: Receiving, opening, tracking and routing Appeal and Grievance mail, faxes, email, voicemail and case correspondence.
- Reviewing Appeal and Grievance correspondence and case requests.
- Create new cases in the health plan appeals and grievances tracking application along with scanned documentation where applicable.
- Intaking, entering, tracking and updating State Fair Hearing (SFH) notices and informing Grievance staff assigned to SFH's of any updates, along with providing administrative support during scheduled SFH's.
- Track appeal requests to the Livanta BFCC-QIO, an independent reviewer, to extend Health plan member covered services.
- Providing outreach to members and provider inquiries and requests through a variety of methods including phone, fax, web, and written correspondence.
- Engages in departmental and cross-departmental training, workgroups, and operational improvement activities, with duties that include but are not limited to: Attending Grievance and Appeals Committee meetings and preparing and presenting agenda items for committee as approved or assigned by Grievance/Appeal Leadership.
- Attending monthly Department meetings and preparing and presenting agenda items for the Department as assigned by Grievance/Appeal Leadership.
- Participating in cross-departmental work groups, grievance system trainings and initiative meetings as assigned.
- Sharing information from workgroups and initiatives with the Grievance/Appeal Team during weekly Team meetings.
- Performing other duties as assigned.
Benefits
- Medical
- Dental
- Vision
- Paid Time Off (PTO)
- Floating Holiday
- Simple IRA Plan with a 3% Employer Contribution
- Employer Paid Life Insurance
- Employee Assistance Program
