Appeals and Grievance Specialist

Presbyterian is seeking a Appeals and Grievance Specialist

Responsible for responding to verbal and written complaints, grievances, and requests for appeals that involve complex matters. Responsible for performing comprehensive research to clarify facts and circumstances. Able to identify the root cause for an issue. Assure that customers and health plan providers receive exceptional service when acknowledging, discussing, documenting or responding to their issue of dissatisfaction. Makes initial decision regarding resolution of complaints, grievances or appeals based on completed research. Responsible for making sure issues are categorized and can be reported to internal stakeholders, oversight committees and regulatory agencies. Able to act as a member advocate in each case, comparing the grievant/appellants issues with the organization s documented facts

 

• This is a Full Time position - Exempt: No
• Job is based at Rev Hugh Cooper Admin Center
• Work hours: Days

Ideal Candidate:  Associates Degree.  One year in a health care environment.  Experience in managed care

• High School education or G.E.D. equivalent required. Associates Degree preferred.
• Three years experience in a customer service setting required of which one year in a health care environment is preferred.
• Experience in managed care field such as Claims or Member Services strongly preferred.
• Experience with healthcare databases is preferred

• Perform research related to the facts and circumstances of a member and provider complaint, appeal, or grievance.
• Gathers necessary documents (from internal and external resources) related to an appeal, grievance or complaint to develop a complete file. Gathers information from clinical sources, medical records, chart reviews, admitting records, patient financial records, and from subject matter experts in order to research the facts of all complaints, grievances and appeals. Uses available documentation including DART, provider manuals, member contracts and online policies and procedures to support accurate and consistent decisions relating to claims payment, authorizations, contractual issues, servicing and care standards, and all other operational aspects of the organization.
• Required to document the substance of each complaint, grievance or appeal case according to legal requirements.
• Responsible for making direct verbal contact with members and providers who have filed a complaint, grievance or appeal during research process in order to fully document the issue. Required to communicate in writing with customers, members, providers or designated representative; using the regulatory compliant format on all issues both for acknowledgment and resolution. All written correspondence must be reviewed for regulatory statutes and requirements for all customer types. Must be able to professionally articulate orally and in writing an understanding of complex issues and detailed action plans.
• Responsible for reviewing research performed by other referral sources, department heads, other departments and conduct more detailed investigative research into the matter to resolve issues of complaint, grievance or appeal.
• Responsible for making decisions in cases of dispute that were not decided or resolved by other referral sources or departments. Such decisions will be made using policy and guidelines, detailed research and applying a standard of reasonableness, considering all actions previously taken by others.
• Responsible for application of contract language from member contracts, provider contracts and employer contracts in researching and deciding outcomes.
• Works closely with Legal/Risk Management, Medical Staff, Medical Directors, Department Directors, regulatory representatives, and outside professional consultants to achieve consistent outcomes in cases of complaints, grievances and appeals.
• Presents completed research file along with recommendation and decision for resolution to the appropriate Appeals and Grievance Coordinator within the time period necessary to remain in compliance with regulatory requirements for appeals, grievances or complaints.
• Responsible for file and documentation preparation of all cases that proceed to further internal or external review and for regulatory and oversight audit activities.

About Presbyterian Healthcare Services
Presbyterian offers a comprehensive benefits package to eligible employees, including medical, dental, vision, disability coverage, life insurance, and optional voluntary benefits.

The Employee Wellness Rewards Program encourages staff to engage in health-enhancing activities - like challenges, webinars, and screenings - with opportunities to earn gift to earn gift cards and other incentives.

As a mission-driven organization, Presbyterian is deeply committed to improving community health across New Mexico through initiatives like growers' markets and local partnerships. Founded in 1908, Presbyterian is a locally owned, not-for-profit healthcare system with nine hospitals, a statewide health plan, and a growing multi-specialty medical group. With nearly 14,000 employees, it is the largest private employer in the state, serving over 580,000 health plan members through Medicare Advantage, Medicaid, and Commercial plans.

AA/EOE/VET/DISABLED. PHS is a drug-free and tobacco-free employer with smoke free campuses.

USD $27.25/Hr.

The compensation range for this role takes into account a wide range of factors, including but not limited to experience and training, internal equity, and other business and organizational needs.