Appeals and Grievances Coordinator

US-LA-Peoples Health- Metairie
Job ID
3503
Category
Professional - All

Overview

Position Purpose and Scope

 

To ensure the quality and integrity of the PHN Appeals and Grievance process.  Will administer the PHN appeals and grievance process, including filing appeals with external review organizations and to ensure timely processing of appeals and grievances.

Responsibilities

Principal Responsibilities

  • Receive and prepare member appeals and grievances including but not limited to research and requests for information
  • Prepare case files for plan decisions
  • Filing appeals with external review organizations
  • Facilitation of plan effectuation
  • Maintains the appeals and grievance database
  • Provides guidance to Member Services and Provider Relations regarding policies and procedures relating to the processing of appeals and grievances
  • Responsible for targeting problem areas in order to ensure correct and timely processing of appeals and grievances
  • Responsible for entire case accuracy and complete
  • Responsible for validation and reporting requirement updates
  • Communicates actively with other departments to resolve issues relating to appeals and grievance processing
  • Special projects as assigned by the Appeals and Grievances Manager
  • Utilize updated resources

 

Core Competencies

  • Professionalism
  • Word processing, spreadsheet and data base management skills required
  • Ability to work independently
  • Excellent oral and written communication skills
  • Ability to meet deadlines

Qualifications

Experience/Education

  • Bachelors degree preferred and/or a minimum of 3 to 5 years related work experience in customer service, appeals and grievances in the managed care industry 
  • Previous experience in a Medicare Advantage plan desired

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