Grievance & Appeals Specialist III
TypeFull-time job
LocationUnited States
Posted2 hours ago
Job Summary:
The Grievance & Appeals Specialist III, in collaboration with department leadership, is responsible for processing and responding to claim appeals and disputes, and provides the department with subject matter expertise in clinical and code edit denials.
Essential Functions:
Review a variety of appeals including, but not limited to: high difficulty appeals, consent appeals, state complaints, dental appeals, low difficulty appeals, member and provider appeals, non-clinical appeals (i.e. tobacco surcharge, etc.), medically frail appeals, RCP appeals
Prepare the appeals for clinical review and be responsible for recording and tracking on a regular basis
Review submitted appeals daily for validation of the appeal
Identify appropriate claim problem within the appeal
Prepare all clinical edit appeals for review by computer research, print claim from Facets system, and print off all the code descriptions to assist the reviewer in decision making for committee meetings
Maintain spreadsheet of all appeals reviewed with the outcomes resulting from the Appeals Committee Meetings
Document within Facets the detailed information as to the outcome of the claim appeal
Identify System changes, log the ticket and track the resolution
Complete claim appeal through claim adjustments or letters of denials
Interact with other departments such as Medical Management, Provider Operation, Provider Service Center and claims
Review claim appeals for possible fraud and abuse and report to Program Integrity
Research and release claim appeals with other health insurance, notifying the COB unit when there is other insurance
Responsible for reviewing and evaluating as a secondary-level review and decision maker on medical record documentation for claims and/or appeals to ensure diagnostic and procedural codes accurately reflect and support the visit as it relates to correct coding guidelines and medical necessity
Analyze and make a determination of appropriate reimbursement for unlisted and by report codes submitted on claims
Responsible for meeting CareSource and associated department standards for timeliness of review claims while maintaining accuracy of medical decisions
Read and interpret medical procedures and terminology by reviewing medical notes
Resolve assigned appeals within regulatory timeframes, achieve departmental quality expectations, and meet daily production requirements
Identify and log any related issues
Prepare packets for and participate in Non Clinical State Fair Hearings
Conduct external review and IRE process for non-clinical requests
Provide escalated effectuation support
Investigation of Recoupment and Arbitration appeals
Provide support to Customer Care Specialists and G&A Specialists to ensure all member grievance and appeals are captured and resolved
Assist Team Leader with monitoring the daily activities of grievance processing for all lines of business
Ensure all grievances are completed timely
Ensure member appeals, access and quality of care issues are resolved within the appropriate time constraints
Assist with the completion required reporting
Assist with the training of new Grievance Specialist and Customer Care Specialists
Assist with the periodic review of grievance and appeals procedures and workflows
Ensure all state inquiries receive responses
Assist with tracking and trending of grievance and appeals data, analyze information to develop proactive interventions
Maintain grievance and appeal information and supporting documentation in accordance with state requirements
Ensure all HIPAA and State requirements/regulations are adhered to at all times
Mentor new staff
Research and resolve CTM complaints
Assist in resolving member and provider grievances, appeals, corporate escalations, state complaints, and BBB complaints
Meet daily production requirements, resolve assigned grievances within regulatory timeframes, and achieve departmental quality expectations
Perform root cause analysis and associated documentation
Serve as an in-person grievance point of contact
Perform UAT testing when necessary
Perform any other job related instructions, as requested
Education and Experience:
High school diploma or equivalent required
Associates Degree or equivalent years of relevant work experience preferred
A minimum of three (3) years of healthcare customer service, claims, compliance or related experience is required, to include one (1) year of coding experience
Competencies, Knowledge and Skills:
Intermediate level skills in Microsoft Word & Excel with Access skills a plus
Strong written and communication skills (written, oral and interpersonal)
Attention to detail
Ability to work independently and within a team environment
Critical listening and thinking skills
Technical writing skills
Time management skills
Proper phone etiquette
Customer service oriented
Decision making/problem solving skills
Strong language skills
Ability to write comprehensive statements using proper grammar and sentence structure
Ability to multitask
Licensure and Certification:
Certified Medical Coder (CPC, RHIT or RHIA) is preferred
Working Conditions:
General office environment; may be required to sit or stand for extended periods of time
Compensation Range:
$47,400.00 - $76,000.00CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type (hourly/salary):
HourlyOrganization Level Competencies
Fostering a Collaborative Workplace Culture
Cultivate Partnerships
Develop Self and Others
Drive Execution
Influence Others
Pursue Personal Excellence
Understand the Business
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.
Brand=CareSourceOriginally posted on Himalayas
The Grievance & Appeals Specialist III, in collaboration with department leadership, is responsible for processing and responding to claim appeals and disputes, and provides the department with subject matter expertise in clinical and code edit denials.
Essential Functions:
Review a variety of appeals including, but not limited to: high difficulty appeals, consent appeals, state complaints, dental appeals, low difficulty appeals, member and provider appeals, non-clinical appeals (i.e. tobacco surcharge, etc.), medically frail appeals, RCP appeals
Prepare the appeals for clinical review and be responsible for recording and tracking on a regular basis
Review submitted appeals daily for validation of the appeal
Identify appropriate claim problem within the appeal
Prepare all clinical edit appeals for review by computer research, print claim from Facets system, and print off all the code descriptions to assist the reviewer in decision making for committee meetings
Maintain spreadsheet of all appeals reviewed with the outcomes resulting from the Appeals Committee Meetings
Document within Facets the detailed information as to the outcome of the claim appeal
Identify System changes, log the ticket and track the resolution
Complete claim appeal through claim adjustments or letters of denials
Interact with other departments such as Medical Management, Provider Operation, Provider Service Center and claims
Review claim appeals for possible fraud and abuse and report to Program Integrity
Research and release claim appeals with other health insurance, notifying the COB unit when there is other insurance
Responsible for reviewing and evaluating as a secondary-level review and decision maker on medical record documentation for claims and/or appeals to ensure diagnostic and procedural codes accurately reflect and support the visit as it relates to correct coding guidelines and medical necessity
Analyze and make a determination of appropriate reimbursement for unlisted and by report codes submitted on claims
Responsible for meeting CareSource and associated department standards for timeliness of review claims while maintaining accuracy of medical decisions
Read and interpret medical procedures and terminology by reviewing medical notes
Resolve assigned appeals within regulatory timeframes, achieve departmental quality expectations, and meet daily production requirements
Identify and log any related issues
Prepare packets for and participate in Non Clinical State Fair Hearings
Conduct external review and IRE process for non-clinical requests
Provide escalated effectuation support
Investigation of Recoupment and Arbitration appeals
Provide support to Customer Care Specialists and G&A Specialists to ensure all member grievance and appeals are captured and resolved
Assist Team Leader with monitoring the daily activities of grievance processing for all lines of business
Ensure all grievances are completed timely
Ensure member appeals, access and quality of care issues are resolved within the appropriate time constraints
Assist with the completion required reporting
Assist with the training of new Grievance Specialist and Customer Care Specialists
Assist with the periodic review of grievance and appeals procedures and workflows
Ensure all state inquiries receive responses
Assist with tracking and trending of grievance and appeals data, analyze information to develop proactive interventions
Maintain grievance and appeal information and supporting documentation in accordance with state requirements
Ensure all HIPAA and State requirements/regulations are adhered to at all times
Mentor new staff
Research and resolve CTM complaints
Assist in resolving member and provider grievances, appeals, corporate escalations, state complaints, and BBB complaints
Meet daily production requirements, resolve assigned grievances within regulatory timeframes, and achieve departmental quality expectations
Perform root cause analysis and associated documentation
Serve as an in-person grievance point of contact
Perform UAT testing when necessary
Perform any other job related instructions, as requested
Education and Experience:
High school diploma or equivalent required
Associates Degree or equivalent years of relevant work experience preferred
A minimum of three (3) years of healthcare customer service, claims, compliance or related experience is required, to include one (1) year of coding experience
Competencies, Knowledge and Skills:
Intermediate level skills in Microsoft Word & Excel with Access skills a plus
Strong written and communication skills (written, oral and interpersonal)
Attention to detail
Ability to work independently and within a team environment
Critical listening and thinking skills
Technical writing skills
Time management skills
Proper phone etiquette
Customer service oriented
Decision making/problem solving skills
Strong language skills
Ability to write comprehensive statements using proper grammar and sentence structure
Ability to multitask
Licensure and Certification:
Certified Medical Coder (CPC, RHIT or RHIA) is preferred
Working Conditions:
General office environment; may be required to sit or stand for extended periods of time
Compensation Range:
$47,400.00 - $76,000.00CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.
Compensation Type (hourly/salary):
HourlyOrganization Level Competencies
Fostering a Collaborative Workplace Culture
Cultivate Partnerships
Develop Self and Others
Drive Execution
Influence Others
Pursue Personal Excellence
Understand the Business
This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.
Brand=CareSourceOriginally posted on Himalayas
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