Appeals & Grievance Coordinator

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Job description

Job Title: Appeals & Grievance Coordinator
Location: Canton MA
Duration: 5+ Months

Summary:
Members and Grievances Department Coordinator assists with all operational aspects of the Member Appeals and Member Grievances process for Commercial TMP and Public Plans products. Responsibilities include but are not limited to: distribution and classification of cases in compliance with applicable time frames and regulations gathering information on behalf of the specialists with external vendors coordinating the request for medical records tracking effectuation facilitating delivery of appeals and related information to key departments and appeals committee members; analyzing andreportingdataregardingdepartmentprocessesasrequestedfrommanagement;note trends in Member 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 regulations. The coordinator must possess broad understanding fall products and benefits as well as understand regulatory requirements and timeframes. The coordinator routinely interacts with providers and other internal and external constituents.

Responsibilities
Assign new verbal and written appeals and grievances to Appeals and Grievances specialists
Enter initial member appeals and grievances data into the system of record and maintain accuracy of appropriate data.
Review all incoming appeals for potential expedites, assign and notify management as appropriate.
Reviews and appropriately classifies grievances and appeals
Track and ensure the timely distribution of all processes addressed by appeals and grievances specialists.
Process Part D Appeals:
Gather appeal information and criteria information from department systems
Outreach to providers for additional information in compliance with CMS guidelines
Summarize and send requests to Medical Directors for decisions
Complete decision letters and verbal notification of outcomes according to CMS guidelines
Process cases according to CMS regulations and time frames
Process Fast Track Appeals including:
Monitors Fast Track appeal phone line and RightFax for new cases and notifies A&G management and Case Management representatives via email
Corresponds with providers and members as required (timely and accurate correspondence and telephone contact as appropriate).
Acts as a liaison to Case Management for obtaining discharge summary to complete DENC's and DNOD's.
Completes data entry and documentation requirements in multiple systems
Escalates issues to Manager, Supervisors, and Case Manager Supervisors as needed to complete DENC's, and DNOD's.
Responsible for compliance with all CMS and Livanta timelines.
Support the specialists in the completion of appeals and grievances including but not limited to
Requesting and tracking receipt of appropriate medical records
Gathering information and uploading to the system of record from external vendors
Identifying and attaching appropriate sections of member EOCs in the appeals file
Printing and distributing appeals packet as needed
Track and complete AOR process
Develop appeals meeting agendas for the various Appeals Committee meetings.
Assists in departmental reporting
Responsible for handling of all A&G mail
Provide in department projects, as assigned

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