We enjoy the important work we do every day on behalf of our members.
Job Summary
Under the general direction of the Appeals and Grievances Supervisor, the Specialist is responsible for ensuring professional handling of all member and provider appeals and grievances in a timely and efficient way. The Specialist must possess broad understanding of all Company products and benefits as well as have an understanding of regulatory requirements and timeframes. Specialists routinely interact with members, providers and other internal and external constituents about highly escalated issues.
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 Tufts Health Plan policies and complex and frequently changing regulatory requirements consistently and the judgment to seek out guidance as needed. The Specialist is responsible for the accurate coordination, efficient administration and resolution of member appeals, provider appeals and member grievances submitted by Point32Health members (member appeals and grievances) or providers (provider appeals) for all products.
The Specialist may work on all of these processes dependent on department workload and work distribution, although typically is assigned a particular function
Job Description
KEY RESPONSIBILITIES/ESSENTIAL FUNCTIONS
Process Member Appeals including:
Receives and performs initial research on member appeals. Categorizes each appeal appropriately.
Corresponds with the member as required (written acknowledgement and closure letters and telephone contact and documentation as appropriate).
Completes data entry and documentation requirements in multiple systems
Acts as a liaison and coordinates functions with internal departments relative to the status of a member appeal and the research needed to prepare the case for review.
Coordinates the gathering of information with external entities not limited to but including providers and clinical consultants
Prepares and presents cases to the Internal Appeals Committees
Prepares cases for External Review.
Interacts with Supervisors, Manager, Medical Directors, Case Management, Precertification,Legal, Member Services and other departments in facilitating identification and resolution of appeals.
Responsible for meeting all regulatory and department timelines.
Process Grievances including:
Receives and does initial research on grievances. Categorizes each grievance appropriately.
Corresponds with the member as required (written acknowledgement and closure letters and telephone contact as appropriate).
Completes data entry and documentation requirements in multiple systems
Acts as a liaison and coordinates functions with internal departments relative to the status of a grievance and the research needed.
Interacts with Supervisors, Manager, Medical Directors, Case Management, Precertification, Legal, Member Services and other departments in facilitating identification and resolution of grievances.
Responsible for meeting all regulatory and department timelines.
Process Provider Appeals including:
Receives and does initial research on provider appeals. Categorizes each appeal appropriately.
Corresponds with the providers as required (written acknowledgement and closure letters and telephone contact as appropriate).
Completes data entry and documentation requirements in multiple systems.
Acts as a liaison and coordinates functions with internal departments relative to the status of a provider appeals and the research needed to prepare the case for review.
Interacts with Manager, Appeals Specialists, Medical Directors, Case Managers, Claims department,Legal Department Representatives, Quality Assurance and other departments facilitating the identification and resolution of provider appeals.
Process Fast Track Appeals and CTM (Complaint Tracker Modules) including:
Corresponds with providers and members as required (timely and accurate correspondence and telephone contact as appropriate).
Acts as a liaison and coordinates functions with internal departments relative to the status of DENC's, DNOD's and the research needed to prepare the case for review, including the administrative sorting of medical records related to Fast Track Appeals.
Completes data entry and documentation requirements in multiple systems.
Interacts with Manager, Supervisors, Medical Directors, Case Managers, Claims department Legal Department Representatives, Quality Assurance and other departments in facilitating the identification and completion ofDENC's, and DNOD's.
Interacts with Manager, Customer Services, Medical Directors, Case Managers, Claims department Legal Department Representatives, Quality Assurance and other departments
Liaison with CMS Regional Office in researching and resolving CTM issues
Responsible for detailed documentation within the CMS system of research and resolution of CTMs
Responsible for meeting all regulatory and department timelines.
Requirements
EDUCATION:
A Bachelor's Degree is preferred in health care management, business, or related field (equivalent experience may be considered).
EXPERIENCE:
Two to three years of office experience with emphasis in customer service required. Effective interpersonal/communication skills are essential. Knowledge of basic medical terminology a plus.
SKILL REQUIREMENTS:
Demonstrated proficiency in operating a personal computer and related equipment including knowledge and demonstrated ability in the use of Windows applications and other comparable systems/applications.
Must possess initiative, balanced judgment, objectivity and the ability to independently plan and prioritize one's own work to assure maximum efficiency.
Must be able to organize, plan and implement the functions of Member Appeals and Grievances and Provider Appeals, maintain timelines and turnaround times to meet multiple requirements/regulations established by external regulating bodies and applicable state and federal laws
Demonstrated ability to synthesize and process complex information and deliver the information, both verbally and written, in a clear, concise, and articulate manner. Requires strong verbal and written skills to effectively communicate at both detail and summary levels to a variety of constituents.
Requires excellent interpersonal skills in order to communicate and work with multiple constituents. Must be able to exercise patience and high level of diplomacy to recognize politically sensitive issues.
WORKING CONDITIONS AND ADDITIONAL REQUIREMENTS (include special requirements, e.g., lifting, travel, overtime)
Fast paced office environment handling multiple demands.
Must be able to exercise appropriate judgment.
Extensive use of PC required and moderate phone usage.
May require occasional weekend hours or evening hours as the needs of the organization/project dictate.
CONFIDENTIAL DATA: All information (written, verbal, electronic, etc.) that an employee encounters while working at Point32Health is considered confidential. Exposed to and required to deal with highly confidential and sensitive material and must adhere to corporate compliance policy, department guidelines/policies and all applicable laws and regulations at all times.
What we build together changes our customer's health for the better. We are looking for talented and innovative people to join our team. Come join us!
