Research and Investigate member and/or provider appeals and grievance requests, includes review of UM/claim denial reasons, contract/regulatory rules, benefits and documentation received on appeal/grievance.
Outreach call(s) made to members/participants, providers and /or member/participant representatives, to acknowledge receipt of appeal/grievance and discuss intent of appeal/grievance. Explain the appeal/grievance process including helping members understand the outcome and implication of appeals decisions.
Prepares case file (original denial, all information received on appeal, medical records, etc.).
Schedule participant/member for committee panel sends scheduling letter if needed.
Prepares, develops and presents written case summaries, if needed and process dictates, for all adverse determination for the purpose of conducting State Fair Hearings.
Prepare and send case files to other teams as needed (e.g. legal, external appeals, state fair hearings, etc.).
Communicates updates and status of outstanding member and provider complaints/issues to management.
Monitors to ensure that all problems with appeals/grievances presented by plan members/participants are resolved in accordance with established policies and procedures.
Update and/or generate authorization updates requests, for services that have been appealed.
Maintains accurate, timely, and complete record of appeals and grievances in the appeals system and documents, all correspondence with a member/participant, representative and/or a provider, related to an appeal or grievance issue.
Maintains quality and compliance standards as dictated by the state and federal entities
Maintains contractual agreements with participating providers related to appeals and grievances.
Monitors caseload daily to ensure all cases are kept within compliance; follows up and escalates when compliance standards are at risk.
Actively seeks the involvement of the legal department or compliance department, as necessary, for clarification and supporting documentation by escalating issues to appeals and grievances management.
Obtain authorization for release of sensitive and confidential information.
Keeps current with rules, regulations, policies and procedures relating to Plan member benefits, member’s rights and responsibilities, and Complaints and Grievances.
Ensure case file is sent to the appropriate committee for decision making or example, internal committee/panel, independent review organization, internal medical director - as process dictates.
Provide support presenting cases and facilitating committee meetings as needed.
Send appeal to an independent review organization portal, for those appeals that require an external match specialty review.
Obtain data from multiple systems/vendors to ensure all documentation needed for appeal is obtained,
Collaboration with internal counterparts as needed to ensure proper handling of the appeal e.g. UM team, medical directors, claims, contact center, vendors as needed.
Creates a decision letter with detailed description of the nature of appeal / grievance including rationale for the decision and options for moving forward.
Initiate and follow up on effectuations (um authorization update/claim adjustment) for overturned appeals/grievances.
All other duties as assigned
Start date-ASAP
Contract-3+ months
*This is an independent contractor role paid on 1099
Job Types: Full-time, Contract
Pay: $40.00 per hour
Expected hours: 40 per week
Standard shift:
Weekly schedule:
Experience:
- Appeals and Grievances intake: 2 years (Required)
- Managed Care: 2 years (Required)
License/Certification:
- RN License in CO or compact (Required)
Work Location: Remote
