Grievance & Appeals Coordinator
Company: Community Care HMO
Location: Tulsa
Posted on: August 5, 2022
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Job Description:
JOB SUMMARY:Responsible for all written inquiries from members
seeking resolution through the grievance and appeals process.KEY
RESPONSIBILITIES:Researches member issues and prepares grievance
and appeals information for each level of the appeal process.
Responsible for adhering to established grievance and appeals
timeframes. Assures compliance with Federal, State and
Accreditation regulations. Receives and responds to member and/or
provider written and oral complaints and requests in accordance
with CommunityCare's grievance and appeals procedures. Ensures
appropriate file documentation that demonstrate process steps.
Interacts with Medical Management, Member Services, Claims,
Pharmacy, Provider Services as well as Senior Management to resolve
issues. Interacts with members, providers, and attorneys who
represent the member regarding the grievance and appeals process.
Interacts with Center for Medicare and Medicaid Services (CMS) and
MAXIMUS Federal Services as indicated. Ensures the grievance and
appeals electronic tracking system (GATS) is populated correctly
and completely for each case. Participates in the audit
process.Notifies members and/or providers in writing of the
decision made at each level of the appeal process. Coordinates with
the Claims, Pharmacy helpdesk and or Medical Management to ensure
that authorization is obtained and claim payment is processed, if
indicated. Prepares grievance and appeal files for audit. Assist
Supervisor with special projects and CMS quarterly reports as it
relates to Grievance and Appeals. Explains policies, procedures,
available benefits and service options to members and/or providers
related to the grievance and appeals process.For inquiries
forwarded from the Department of Insurance, adheres to all
specified communication and timeframe requirements. Documents
accordingly in the file.Work may involve dealing with members who
are disgruntled or upset.Perform other duties as
assigned.QUALIFICATIONS:Customer service experience in managed
care, insurance or healthcare environment required.Successful
completion of Health Care Sanctions background check.Possess strong
oral and written communication skills.Ability to work on multiple
tasks.Proficient in Microsoft applications.Highly organized and
attentive to detail.EDUCATION/EXPERIENCE:High school diploma or
equivalent PLUS 5 years related experience OR Associates degree
plus 1 year of related experience required.Related experience
consists of customer service, member service or claims processing
in an insurance environment. Managed care experience preferred.
Keywords: Community Care HMO, Tulsa , Grievance & Appeals Coordinator, Other , Tulsa, Oklahoma
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