Appeals & Grievance Coordinator II

Beacon Health Options
Published
May 21, 2020
Location
Grand Rapids, MI
Job Type
 

Description

Beacon Health Options

Job Category: Clinical - Grievance/Appeals
Req #: APPEA02270
Schedule: Full Time
Location: MI - Grand Rapids

About the Position:

Beacon Health Options is currently seeking a dynamic Appeals & Grievances Coordinator II to join our team in Grand Rapids, MI. The Appeals & Grievances Coordinator II responsible for the processing, tracking and follow up of all medical necessity denials and appeals and Fair Hearings resolution for commercial products and government programs. This individual is required to have the ability to provide excellent customer service to providers and members and the ability to perform in potentially stressful situations, such as state, federal, NCQA, URAC or other regulatory / accrediting agency audits.

Position Responsibilities:

  • Maintains systems and processes for the timely and accurate resolution of all medical necessity denials, appeals, and fair hearings including the tracking of information, system documentation, sending adverse determination letters to providers and members within established client service level agreements, performance guarantees and regulatory requirements.
  • Review Peer Advisor and/or Clinician determinations to ensure that regulatory, accreditation, and client requirements are adhered.
  • Compose decision letters under the direction of utilization management, clinical operations, and issue final determination response to member and provider.
  • Responsible for verbal communications of denial, appeal and fair hearing outcomes to member and providers.
  • Manages case assignments including appeal review scheduling, point of contact for appeal requestor to respond to questions concerning the appeal process, quality assurance process for appeal resolution letter, and liaison for functional inter-departmental dependencies.
  • Support and manage appeal inventory queues for timeliness, appeal documentation, and case management according to client performance guarantees and departmental service level agreements.
  • Provide assistance and guidance to Appeals Coordinator staff as needed; identifying training and development needs as required with recommended action plans to Manager.
  • Lead and support the research, analysis and resolution of complex denial, appeals and fair hearings, identifying trends to improve efficiencies and quality of service.
  • Assists in quality management as required including client and corporate audits, accreditation, quality improvement initiatives, and performance standard teams.
  • Resolve appeal call contact follow ups and escalations triage from Service Operations or management.
  • Responsible for processing fax and email receipts of appeal requests including building appeal cases, triage to clinical operations and/or National scheduling, and detail case documentation.
  • Attend and Represent the company in Fair Hearing proceedings.
  • Other duties as assigned.

Position Requirements:

  • Education:A.A.S. degree required, B.S. degree preferred
  • Relevant Work Experience: 2 years of experience in healthcare, behavioral health, or a related field required
  • Travel: up to 10% local travel required
  • Licensure: unrestricted driver's license required

Beacon Health Optionsis proud to be an Equal Opportunity and Affirmative Action Employer as well as a Drug Free and Tobacco Free Work Environment. EOE/AA/M/F/Veterans/Disabled

At Beacon Health Options, our candidate's data privacy is a top priority. Our recruiting team conducts all communications using official company email (@BeaconHealthOptions.com). Only candidates who have applied for an open position through our Careers page (careers.beaconhealthoptions.com) will be engaged in our interview process. Beacon conducts all interviews in person or over the phone. At no time during the recruiting process will any Beacon recruiter request any financial or personally identifiable information from you.

#CB

#GD

PI120360217

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