Full time Grievance and Appeals Coordinator openings in the Houston, TX 77027 area with a major healthcare company! Starting ASAP!! Apply now to Thu Phan with A-Line!
- PAY RATE: $19/hour
- HOURS: Fill time- 40 hrs per week - Monday through Friday from 8AM-5PM
Grievance and Appeals Coordinator Job Responsibilities:
- Ability to effectively communicate, present information and respond to questions from clinical and non-clinical Appeals staff, other departments, providers and members.
- Ability to write concise, grammatically correct notes and business correspondence.
- Ability to review correspondence and system data to establish facts and draw valid conclusions consistent with applicable policy and procedures with minimal supervision.
- Logs, tracks, and processes health service appeals.
- Serves as a liaison in corresponding and communicating with providers and members or members’ representatives as needed during appeal processing.
- Interacts with other departments including Customer Service, Claims, Provider Relations and Pharmacy to resolve member and provider appeals.
- Makes administrative appeal determinations when indicated and properly sets up case files for clinical review when needed.
- Conducts general appeal research and filing including, but not limited to, requesting waivers of liability and/or appointment of representative forms, organizational determination research, requesting member medical records, organizing documentation, preparing written summaries, scheduling the case, processing the review of case, documentation of the appeal resolution and sending completed case files to external review organizations as required by regulatory guidelines.
- Maintains all documentation associated with the processing and handling of appeals to comply with regulatory standards and timeframes while maintaining an accurate, complete appeals record in the electronic database.
- Performs administrative activities including, but not limited to, generating, printing and mailing determination and authorization notification letters.
- Completes all associated data entry and authorization creations in systems. Correctly and completely preps completed case files for scanning and archiving.
- Develops and presents ideas for performance and process management improvement within the department. Notifies Supervisor or other appropriate parties of identified patterns of appeals, claim errors, configuration issues, or other systemic problems identified during appeal processing.
- Performs special projects as needed.