Appeals and Grievance Specialist II

9165136 - Appeals and Grievance Specialist II - Irving, TX – 12-week Contract

Sigma Inc. is currently looking for Appeals and Grievance Specialist to work in Irving

Shift Details: Monday-Friday 8 hours

Summary:

• This position requires the ability to work independently researching and reviewing inquiries from members and providers.
• Also requires knowledge of benefit interpretation, claims reviews, CPT and ICD coding.
• Responsible for reviewing, classifying, researching and resolving member complaints (grievances and/or appeals) and communicating resolution to members or their authorized representatives in accordance with the standards and requirements established by the Centers for Medicare and Medicaid Services and TRICARE.
• Coordinates with pertinent departments to effectuate resolution resulting from grievance and appeals resolution decisions made at the plan level or by independent review entities.
• Adheres to client Plan policies and procedures which are based on regulated state and federal policies pertaining to the processing of grievances and appeals.
• Analyzes grievance and appeals data and develops tracking and trending reports at prescribed frequencies for the explicit purpose of identifying and communicating trended root causes of member and provider dissatisfaction.
• Recommends process improvements to pertinent departments within the Client Plan organization in order to achieve member and provider satisfaction and/or operational effectiveness and efficiencies which contribute to maximum Medicare STAR ratings.

Responsibilities:

• Research and provide resolution to issues such as claim denials, member and provider complaints, and reconsideration and redetermination requests.
• Integrate and analyze information from several sources and problem solve towards a resolution within tight timelines.
• Be able to summarize and communicate a member or provider case to others for the purpose of facilitating a fair decision and fulfilling standards and requirements of the regulatory agency.
• Interact well with both internal and external customers along with strong organizational and time management skills.
• Abilities to interpret and communicate data and trends to a management audience.
• Proficient in Word and Excel.
• Knowledge of medical terminology, Medicare coding and Medicare-covered benefits preferred.
• Excellent verbal and written communication skills.
• Ability to maintain attendance to support required quality and quantity of work.
• Ability to establish and maintain positive and effective work relationships with coworkers, clients, members, providers and customers.
• Be proactive in educating members, providers and others about CHRISTUS Health plans appeal/grievance process, plan terminations, contract terminations and benefit summary.
• Certify that providers and members are reimbursed accordingly using Medicare or other applicable plan reimbursement policies and procedures.
• Maintain accurate and timely responses to inquiries and generate appropriate letters to members and providers informing them of appeal/grievance decisions.
• Provide recommendations and direction to both servicing providers and members in attempt to eliminate repeated disputes between providers and CHRISTUS Health Plan.
• Follow the CHRISTUS Health guidelines related to Health Insurance Portability and Accountability Act (HIPAA), designed to prevent or detect unauthorized disclosure of Protected Health Information (PHI).
• Attend weekly and monthly team and department meetings as appropriate.
• Ability to sit for long periods of time.
• Ability to organize and prioritize work to meet deadlines.
• Ability to work occasional long or irregular hours.
• Ability to work flexible work schedule including evenings and weekends.

Requirements:

• Minimum of three years customer service experience with Managed Care Plans.
• Previous Appeals and Grievance experience with Managed Care Plans.
• Minimum of two years appeal and grievance experience with Managed Care Plans
• Good typing and letter writing skills.
• Excellent written and oral communication skills.
• Excellent research and analytical skills.
• Basic computer knowledge.
• Excellent customer service skills.
• Ability to work well with diverse groups of individuals.
• Utilizes effective communication and conflict management skills.