Job Description

The Appeals and Grievance (A&G) Coordinator is responsible, per State and Federal regulations, for assisting with all operational aspects of the Appeals and Grievances assignment process for Point32Health. Responsibilities include, but are not limited to: processing daily mail received by the A&G department, distribution and classification of cases in compliance with applicable timeframes and regulations, gathering information on behalf of the A&G Analyst with external vendors, coordinating the request for medical records, tracking effectuations, facilitating delivery of appeals and related information to key departments and appeals committee members; analyzing and reporting data regarding department processes as requested from management; note trends in Appeals and Grievances and notify supervisors of their findings and ensuring professional handling of Medicare Part D Appeals and Fast Track Appeals timely and in compliance with CMS regulations. The coordinator must possess broad understanding of all Point32Health lines of business and benefit structures as well as have an understanding of regulatory requirements and timeframes. The Coordinator routinely interacts with providers and other internal and external constituents.

Essential functions will occur simultaneously; therefore, the employee must be able to appropriately handle each of these functions, prioritize them, and seek assistance when necessary. These essential functions need to be performed on a consistent and regular basis, using good judgment. The employee must have the ability to learn and apply Point32Health\xe2\x80\x99s policies and complex and frequently changing regulatory requirements consistently and the judgment to seek out guidance as needed.

Key Responsibilities/Duties \xe2\x80\x93 what you will be doing

• Assign new verbal and written appeals and grievances to Appeals and Grievances Analyst
• Process Fast Track Appeals including monitoring of Fast Track appeals phone line and rightfax for new cases, functioning as a liaison between A&G, Care Management, and Independent Review Organization (IRO)
• Support A&G Analyst in timely completion of Appeals and Grievances
• Adheres to all regulatory and compliance timeliness expectations
• Responsible for distribution of incoming mail as well as department manual mail processing.
• Other duties and projects as assigned.

Qualifications \xe2\x80\x93 what you need to perform the job

EDUCATION, CERTIFICATION AND LICENSURE:

• Associates Degree or equivalent experience in health care, conflict resolution or related field

EXPERIENCE (minimum years required):

• 1-2 years of experience in a health care and/or administrative setting preferred

SKILL REQUIREMENTS:

• Excellent organizational skills required.
• Excellent interpersonal/communication skills are essential. Must have computer skills with experience in EXCEL, and WORD. Must have knowledge and demonstrated ability in the use of Windows applications and other comparable systems/applications.
• Knowledge of basic medical terminology a plus.
• Knowledge of basic medical terminology.
• Individual must be able to appropriately identify urgent situations and follow the appropriate protocol. Position also requires the ability to manage multiple priorities as well as having the initiative, judgment, and perception to operate within a fast paced, high stress environment.
• Individual must possess strong organizational, logical reasoning, analytical, and problem-solving skills as well as the attention to detail necessary to act within this complex environment.
• Individual must also be able to work independently but be able to identify when they should ask for help. The individual should be flexible to respond to changing needs in the Department.
• Must be able to work well independently and as a team member. Must be able to work closely with other department staff and must have work coverage plan in place in preparation for scheduled and unscheduled absences, due to importance of position to department\xe2\x80\x99s compliance with various processes.
• Requires excellent interpersonal skills and an ability to recognize and understand sensitive customer-oriented issues.
• Position also requires daily contact, by telephone, with members, providers, and internal departments.

WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS (include special requirements, e.g., lifting, travel):

• Must be able to work under normal office conditions and in a remote capacity from home as required.
• Work requires simultaneous use of a telephone/headset and laptop/keyboard and sitting for extended durations.
• May be required to work additional hours beyond standard work schedule.
• May require occasional weekend hours or evening hours as the needs of the various lines of business dictate.

Who We Are:

Point32Health is a leading health and wellbeing organization, delivering an ever-better health care experience to everyone in our communities. Building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.

At Point32Health, we\xe2\x80\x99re working to reshape the world of health care by pushing past the status quo and delivering even more to the diverse communities we serve: more innovation, more access, more support, and healthier lives. And we want people like you on our side to make it even better.

This job has been posted by Ignyte AI on behalf of Point32Health. Ignyte AI is committed to the fundamental principle of equal opportunity and equal treatment for every prospective and current employee. It is the policy of Ignyte AI not to discriminate based on race, color, national or ethnic origin, ancestry, age, religion, creed, disability, sex and gender, sexual orientation, gender identity and/or expression, military or veteran status, or any other characteristic protected under applicable federal, state or local law.

Req ID: R6779

Point32Health