Job Description Summary

Coordinate the internal appeals and grievances process by supporting entry of requests in a meaningful and timely manner. Provide support as needed for the completion of appeals and grievances. Communicate information about appeals and grievances processes and outcomes to members and providers verbally and/or in writing. Support member and provider experience.

Essential Responsibilities:

• Oversee and coordinate all Appeal activities, ensuring response deadlines are met by applicable best practices, state and federal guidelines.
• Draft and provide acknowledgements by applicable method, to inquiries and appeals as required by regulations, policy and department process standards.
• Ensure accurate and complete entry of case-specific information into the Health Management Platform.
• Review the original adverse benefit determination and provide information in the case to inform further processing.
• Prepare and provide responses and resolution by applicable method to inquiries and appeals as required by regulations, policy and department process standards.
• Collaborate with team members to manage the timeliness of cases.
• Identify needs of the case spanning Commercial, Medicaid, and Medicare plans based on applicable state, federal, and NCQA guidelines.

Supporting Responsibilities:

• Assist the Appeals and Grievances Support team in the entry of new appeals and grievances into the system.
• Meet department and company performance and attendance expectations.
• Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• Perform other duties as assigned.

SUCCESS PROFILE

Work Experience: Minimum of two years of customer service, claims processing, or health insurance industry experience required. 1 year of technical writing and conflict resolution experience preferred.

Education, Certificates, Licenses: High School Diploma required; bachelor’s degree or equivalent experience preferred.

Knowledge: Requires strong research, analytical, and data entry skills. Experience using Facets, Onbase, and other software packages. Must have basic math skills, the ability to work under strict deadlines, and excellent organizational skills.

Competencies

Adaptability

Building Customer Loyalty

Building Strategic Work Relationships

Building Trust

Continuous Improvement

Contributing to Team Success

Planning and Organizing

Work Standards