Appeals and Grievances Associate
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Job Description:
This position located at a healthcare insurance company is responsible for capturing and resolving complaints, complaint appeals and grievances for members in the Medicaid and Medicare lines of business within the timeframes outlined by federal and state regulations.

• Review Appeals & Grievance compliance/regulatory reports (quarterly and annual); research inconsistencies and errors, provide corrections, interface with external vendor and internal colleagues to ensure accurate reports with auditable documentation.

Research complaints, complaint appeals or grievances that initiate from a variety of sources, including members, providers, state/federal regulators, and others within the timeframes outlined by federal and state regulations.
• Gather comprehensive documentation from varied internal and external sources relevant to issue raised in complaint, complaint appeal or grievance. Ensure departments are responding to inquires in a timely fashion.
• Prepare member correspondence, as appropriate in relationship to complaints, complaint appeals or grievances, consistent with HIPAA regulations and company protocol.
• Use critical thinking to investigate and correctly categorize cases and determine a course of review action and parties to contact. Accurately identify the different types of complaints. Prepare quality of care issues for further medical review by securing medical records pertinent to the complaint, complaint appeal or grievance
• Assist with the preparation of materials for the monthly and quarterly complaint and grievance committee meetings.
• Present cases for review at the appropriate committee meetings.
• Document and maintain accurate complaint, complaint appeal or grievance records in the designated databases with attention to detail. Modify department assignments as appropriate, and follow-up on resolutions as needed. Ensure all payments related to complaints, complaint appeals or grievances are processed via the claim system and track until payment is finalized.
• Process correspondence to member, timely and in accordance with federal/state regulations and established policies for all lines of business.
• Maintain company compliance by resolving and closing complaint, complaint appeal or grievance within the timelines established by regulatory agencies and the plan, according to the processes established by the plan

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Experience Level:

• Associates Degree or, an equivalent combination of education and relevant work experience required. Bachelor?s Degree in Business, Health Administration or a related field preferred.
• Minimum two (2) years? of complaints and grievances experience in a Medicare and/or Medicaid environment. Extensive knowledge of Medicaid and Medicare regulations is preferred.
• Minimum two (2) years of claims experience; strong claims background and has worked with claims within an insurance company/medical group. Must be fluent in medical claims coding concepts, though certification as a coder is not required.
• Must be able to demonstrate the differences between an appeals and grievances.
• Intermediate level of proficiency with Microsoft Word and Excel.
• Demonstrate ability to work independently under time pressure.
• Excellent verbal, written and interpersonal skills are required; bilingual in English and Spanish preferred.
• Demonstrate understanding and sensitivity to multi-cultural values, beliefs, and attitudes of both internal and external contacts.
• Demonstrate appropriate behaviors in accordance with the organization?s vision, mission, and values
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New York NY

Contract to Direct

Pay Rate:
$50k - $100k

Date Posted: 08/01/2016
Last Updated: 08/01/2016