Appeals and Grievances Coordinator

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 Point32Healths policies and complex and frequently changing regulatory requirements consistently and the judgment to seek out guidance as needed.

Key Responsibilities/Duties - 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 - 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 departments 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.

Commitment to Diversity, Equity & Inclusion

Point32Health is committed to making diversity, equity, and inclusion part of everything we dofrom product design to the workforce driving that innovation. Our DEI strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent. We welcome all applicants and qualified individuals, who will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

Who We Are

Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where 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.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities.

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: R7749