JOB SUMMARY
Responsible for all inquiries from members and providers seeking resolution through the grievance and appeals process.
KEY RESPONSIBILITIES
Investigates complaints and communicates resolution to member or authorized representatives for all lines of business in accordance with CommunityCare s grievance procedures.
Investigates prepares case files and presents cases for medical andor administrative review. For all lines of business for post-service claims appeals and standard pre-service claims appeals. Assures compliance with Federal State and Accreditation regulations and CommunityCare s appeal procedures and timeframes. Prepare higher level appeal case packets. Interacts with Medical Management Member Services Claims Pharmacy Provider Services as well as Senior Management to resolve issues and other internal process owners as indicated.
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 and other regulatory entities as indicated. Maintains appropriate file documentation that demonstrates process is followed and accurately entered in the system.
Notifies members andor 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 andor providers related to the grievance and appeals process.
For inquiries received from the Department of Insurance adheres to all specified communication and timeframe requirements. 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 reason logically and to use good judgment when interpreting materials or situation.
Ability to organize time effectively and set priorities. Proficient in Microsoft applications.
Highly organized and attentive to detail.
EDUCATION/EXPERIENCE
High school diploma or equivalent PLUS 3 years related experience OR associate degree plus 2 years of related experience required.
Related experience consists of customer service member service or claims processing in an insurance environment. Managed care experience preferred.
CommunityCare is an equal opportunity at will employer and does not discriminate against any employee or applicant for employment because of age race religion color disability sex sexual orientation or national origin