Position Purpose: Analyze and resolve verbal and written claims and authorization appeals from providers and pursue resolution of formal grievances from members.
Education/Experience: High school diploma or equivalent. Associate s degree preferred. 2+ years grievance or appeals, claims or related managed care experience. Strong oral, written, and problem solving skills.
" Gather, analyze and report verbal and written member and provider complaints, grievances and appeals
" Prepare response letters for member and provider complaints, grievances and appeals
" Maintain files on individual appeals and grievances
" May coordinate the Grievance and Appeals Committee
" Support the pay-for-performance programs, including data entry, tracking, organizing, and researching information
" Assist with HEDIS production functions including data entry, calls to provider s offices, and claims research.
" Manage large volumes of documents including copying, faxing and scanning incoming mail
EEO:
Mindlance is an Equal Opportunity Employer and does not discriminate in employment on the basis of Minority/Gender/Disability/Religion/LGBTQI/Age/Veterans.
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| Story Behind the Need |
- What is the purpose of this team?
- What is driving this need? (ex. Backfill for FTE or CW, new project, business growth)
- Describe the surrounding team (team culture, work environment, etc.) & key projects.
- Do you have any additional upcoming hiring needs, or is this request part of a larger hiring initiative?
| - Purpose to assume intake work from the production team.
- Driving the need based on membership instability and high regulatory cases loads this function can no longer be performed by the existing production liaisons.
- Surrounding Team Very established, great leaders, continually helping each other, really display all Centene values, patient and supportive.
- No additional hiring needs are known at this time.
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| Typical Day in the Role |
- Walk me through the day-to-day responsibilities and a description of the project (Outside of the Workday JD).
- What are performance expectations/metrics?
- What makes this role unique?
| This role is dedicated to triage incoming cases same day from 8:00 a.m. CST to 5:00 p.m. CST. It involves retrieving documents from various source (fax, email, prime workbasket) determine appropriate classification, route accordingly using pre-established job aids.
Performance expectations are being present, adhering to the FaxCom schedule. Must be some one familiar with Microsoft office systems and also have good communication skills to work with liaison as necessary who receive the work. It is a busy role, expectations are strong, yet not unachievable. This person will be trained on one station to monitor at a time. Must be able to read and interpret member complaints. |
| Candidate Requirements |
| Education/Certification | Required: High School, GED | Preferred: |
| Licensure | Required: None | Preferred: |
Years of experience required: Healthcare experience is preferred, not a requirement. Fast paced office experience is a plus. Must be organized, attentive to their role. Must be engaged with the team.
Disqualifiers:
Additional qualities to look for: Writing skills, organizational skill, accuracy, good eye for detail |
- Top 3 must-have hard skills stack-ranked by importance
| 1 | Multi-task |
| 2 | Organized |
| 3 | Fast pace environment serving customers |
| Candidate Review & Selection |
- Shortlisting process
- Candidate review & selection
- Interview information
- Onboard process and expectations
| Projected Manager Candidate Review Date: | 1-2 days post shortlisting |
Type of Interviews:
| Teams/Zoom |
| Required Testing or Assessment (by Vendor): | Computer skill accuracy is key. Multitasking, busy environment. Dedicated hours and attendance. |
| Next Steps |
- Do you have any upcoming PTO?
| Yes 10/29, 10/30 and 11/3 |
- Colleagues to cc/delegate
| Cristina Baker |