Grievance & Appeal Representative

Job Description

Job DescriptionDescription:

Verda Health Plan of Texas has a contract with the Center of Medicaid and Medicare Services (CMS) and a state license with the Texas Department of Insurance for a Medicare Advantage Prescription Drug (MAPD) plan. We are committed to the idea that healthcare should be easily and equitably accessed by all. Our mission is to ensure that underserved communities have access to health and wellness services, and receive the support needed to live a healthy life that is free of worry and full of joy. We are looking for a Grievance & Appeal Representative to join our growing company with many internal opportunities.

Are you ready to join a company that is changing the face of health care across the nation? Verda Healthcare, Inc is looking for people like you who value excellence, integrity, caring and innovation. As an employee, you’ll join a team dedicated to improving the lives of our Medicare members. Our vision incorporates value-based health care that works. We value diversity.

Align your career goals with Verda Healthcare, Inc and we will support you all the way.

Position Overview

The Grievance & Appeal Representative responds to all types of written/verbal grievances, complaints, appeals and disputes submitted by members and providers: review, analyze, research, respond and resolve all inquiries, in accordance with guidelines established by CMS and other regulatory agencies, where applicable, as well as internal policies. Will work with Clinical department regarding appeals related to Clinical policy. Work as an effective interface between internal and external customers. Maintain good member and provider relations relationship.

****This position is part of Call Center. This position reports to the Manager of Enrollment.

Job Responsibilities

· Review and evaluate appeal and grievance request to identify and classify member and provider appeals, hand-off to appropriate department for provider and clinical appeals; process member and provider complaints as appropriate to meet the CMS, State and Accreditation requirements.

· Determine eligibility, benefits, and prior activity related to claims, payment or service in question.

· Review research performed by operational areas to ensure the appropriate resolution to the appeal/grievance has been achieved, review contracts, member materials, medical payment policies, and provider education documents in researching and deciding the outcome of appeals.

· Accountable for appropriate review and determination in compliance with state and federal regulations.

· Conduct thorough investigations of all member and provider correspondence by analyzing all the issues involved and obtaining responses and information from internal and external entities.

· Perform comprehensive research related to the facts and circumstances of a member complaint, to include appropriate classification as a grievance, appeal, or both, in accordance wit regulatory requirements.

· Research appeal files for completeness and accuracy and investigate deficiencies. Consult with internal areas as required (such as the Legal Department) to clarify legal ramifications around complex appeals.

· Provide written acknowledgement of member and provider correspondence, prepare written responses to all member and provider correspondence that appropriately address each complaint’s issues and are structurally accurate.

· Follow-up with departments responsible to ensure compliance.

· Responsible for making verbal contact with the member or authorized representative during the research process to further clarify, as needed, for the member’s complaint.

· Ensure documentation requirements are met create and document service requests to track and resolve issues; document final resolutions along with all required data to facilitate accurate reporting, tracking and trending.

· Provide all follow up documentation of outcome to practitioners, providers, and members.

· Responsible for the timely, complete, accurate documentation of the appeal and/or grievance both electronically, and hard copy, and for timely and accurate written documentation to the member and/or provider advising of the resolution of the appeal and/or grievance.

· Responsible for ensuring appeals case files are accurately prepared and submitted to the IRE within 24 hours of the decision to uphold the initial denial for expediated appeals, and not later than 30 calendar days after the receipt of a standard pre-service appeal and 60 days after the receipt of a claim appeal.

· Enter and maintain critical data and records in support of Verda Health Plan business requirements, regulatory obligations timeframes, monitor daily and weekly pending reports and personal worklists, ensuring internal and regulatory timeframes are met.

· Enter and maintain critical data and records in support of business requirements, regulatory timeframes, and NCQA standards, into the appropriate systems.

· Track and trend outcomes and analyze data to provide reporting as required for UM, QA, etc. and to identify provider education opportunities.

· Responsible for monitoring the effectuation of all resolution/outcomes resulting from the appeals, Administrative Law Judge, and Medicare Appeals Council processes.

· Identify areas of potential improvement and provide feedback and recommendations to management on issue resolution, quality improvement, network contracting, policies and procedures, administrative costs, cost saving opportunities, best practices, and performance issues.

· Serve as liaison with medical groups and network physicians to ensure timely resolution of cases; collaborate and partner with internal departments for resolution and education, work with physicians, hospitals and internal staff to gather information needed to resolve complex claim issues.

· Perform other tasks, projects, etc. as needed or directed

Requirements:

Minimum Qualifications

· Associate’s degree required, Bachelor’s preferred.

· In lieu of degree, equivalent education and/or experience may be considered.

· 3+ years of related, professional work experience required.

· 2 years’ experience in Medicare Managed Care preferred.

· Experience in a managed care/compliance environment preferred.

· Knowledge of medical terminology, provider reimbursement, medical coding, coordination of benefits and all types of medical claims required.

· Solid understanding of member and provider rights and responsibilities, particularly with appeals and grievance required.

· Familiarity with managed care, state and federal regulations is required.

· Prior auditing experience preferred.

· Customer Service experience preferred.

· Knowledgeable in medical terminology and have prior ACD experience.

· Demonstrates good judgment, organization and prioritization skills and time management skills.

· Proven leadership with staff, projects, and management.

· Strategic thinking abilities and analytical skills

· Ability to clearly present written information and findings, concisely communicate concepts and make executive-level presentations.

Professional Competencies

· Integrity and Trust

· Customer Focus

· Functional/Technical Skills

· Written/Oral Communications

· Critical/Analytical Thinker

Verda cares deeply about the future, growth, and well-being of its employees. Join our team today!

Job Type: Full-time

Benefits:

• 401(k)
• Paid time off (vacation, holiday, sick leave)
• Health insurance
• Dental Insurance
• Vision insurance
• Life insurance

Schedule:

• Full-time onsite (100% in-office)
• Hours of operations: 9am – 6pm
• Standard business hours Monday to Friday/weekends as needed
• Occasional travel may be required for meetings and training sessions.

Ability to commute/relocate:

• Reliably commute or planning to relocate before starting work (Required)

PHYSICAL DEMANDS

Regularly sit/walk at a workstation in an office or cubicle setting. Must occasionally lift and/or move up to 25-50 pounds.

*Other duties may be assigned in support of departmental goals.