Receive, review, investigate and resolve member grievances and appeals that are received from IPA contracted health plans. The position will require resolution of the grievance issues in compliance with legal and regulatory requirements.
Duties and Responsibilities
- Receive appeals and grievances form the health plans and set up the case in sPHERICAL Solutions (Grievance/Appeal Internal Database)
- Collects, organizes and tracks information to facilitate and expedite processing of grievances and appeals from a variety of internal and external sources including MPM departments, provider PCP offices, provider specialty offices and ancillary providers
- Tracks receipt of information and performs telephonic, e-mail and faxing follow-up
- Writes letters to health plan summarizing all findings, recommendations and corrective action requirements
- Submits information package along with all medical records, provider letters and MPM summary letter to health plan within requisite time frame (generally 3-7 working days, depending on health plan for standard grievances; 1-3 day times period for expedited grievance requests)
- Records all transactions in sPHERICAL Solutions database
- Completes case in sPHERICAL Solutions
- Closes out case in sPHERICAL Solutions when final letter is received from the health plans
- All other grievance and appeals related functions, upon request
Minimum Job Requirements:
- High School graduate or GED equivalent; Bachelor’s degree in health care related field (preferred)
Knowledge, Skills, and Abilities Required:
- Effective verbal and written communication skills and effective interpersonal skills.
- Positive and approachable demeanor
- Knowledge of medical terminology preferred
- Ability to work well in a fast paced environment and have multi-tasking skills
- Able to stay focused on the telephone even with noise and other distractions
- Minimum or higher proficiency level with Microsoft Office Programs; primarily Word and Excel 2013 or higher
- EZ-CAP® knowledge a plus.