Appeals Coordinator, Geisinger Health Plan (East Coast resident / Eastern Standa
Direct Jobs, Danville, PA, United States
Job Summary
Provides support in administration of the Appeals and Grievance process. Serves as a liaison between Members and the Plan with appeals regarding denied claims/services, referrals, membership and benefit issues and concerns regarding quality of care or service. Presents Member appeals to the Plan Medical Staff and Center for Medicare/Medicaid Services contracted reviewer.
Job Duties
Prepares and facilitates Member appeals, complaints and grievances by communicating directly with Members, their Representatives, Vendors and Medical Providers and their Representatives to obtain the necessary information to complete the appeal process successfully within the time period allowed by regulation.
Investigates the full details of the appeal and complaints and grievances by consulting with, but not limited to, health care providers, legal services, internal medical staff and administration.
Provides timely and accurate documentation of all communications with involved parties within both the individual case file and departmental tracking database.
Ensures that all complaint, appeal and grievance time frames are met as dictated by guidelines set forth by the Department of Labor (DOL), the Department of Health (DOH), the Department of Insurance (DOI), the National Committee for Quality Insurance (NCQA), and the Centers for Medicare and Medicaid Services (CMS).
Implements regulatory changes to current practices, policies and procedures within the Department.
Maintains a complete and accurate database via departmental software for reporting and tracking and trending purposes.
Conducts regular audits of own files and data entry to ensure timely, accurate and appropriate documentation.
Coordinates activities for review committees and educational sessions with other Health Plan departments to ensure overall compliance is maintained.
Acts as the primary resource regarding the complaint, appeal and grievance processes to all other Health Plan and external entities, communicating with all entities involved throughout the appeals and grievance process.
Maintains strict compliance with all applicable laws and regulations set forth by the Federal and State regulatory bodies, continually reviewing updates as pertains to regulatory changes and implement those changes within current departmental practices, policies and procedures.
Makes suggestions for policies and procedures covering all regulatory and accreditation standards for all lines of business.
Work Environment
Work is typically performed in an office environment. Ability to travel is required. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.
Education & Experience
Education: High School Diploma or Equivalent (GED) - (Required)
Experience: Minimum of 5 years Relevant experience - (Required)
Relevant experience may be a combination of related work experience and degree obtained (Associate’s Degree = 2 years; Bachelor’s Degree = 4 years).
Benefits
We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners.
Equal Opportunity Statement
We are proud to be an affirmative action, equal opportunity employer. All qualified applicants will receive consideration for employment regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or status as a protected veteran. Women and Minorities are encouraged to apply. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or their protected veteran status.
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Provides support in administration of the Appeals and Grievance process. Serves as a liaison between Members and the Plan with appeals regarding denied claims/services, referrals, membership and benefit issues and concerns regarding quality of care or service. Presents Member appeals to the Plan Medical Staff and Center for Medicare/Medicaid Services contracted reviewer.
Job Duties
Prepares and facilitates Member appeals, complaints and grievances by communicating directly with Members, their Representatives, Vendors and Medical Providers and their Representatives to obtain the necessary information to complete the appeal process successfully within the time period allowed by regulation.
Investigates the full details of the appeal and complaints and grievances by consulting with, but not limited to, health care providers, legal services, internal medical staff and administration.
Provides timely and accurate documentation of all communications with involved parties within both the individual case file and departmental tracking database.
Ensures that all complaint, appeal and grievance time frames are met as dictated by guidelines set forth by the Department of Labor (DOL), the Department of Health (DOH), the Department of Insurance (DOI), the National Committee for Quality Insurance (NCQA), and the Centers for Medicare and Medicaid Services (CMS).
Implements regulatory changes to current practices, policies and procedures within the Department.
Maintains a complete and accurate database via departmental software for reporting and tracking and trending purposes.
Conducts regular audits of own files and data entry to ensure timely, accurate and appropriate documentation.
Coordinates activities for review committees and educational sessions with other Health Plan departments to ensure overall compliance is maintained.
Acts as the primary resource regarding the complaint, appeal and grievance processes to all other Health Plan and external entities, communicating with all entities involved throughout the appeals and grievance process.
Maintains strict compliance with all applicable laws and regulations set forth by the Federal and State regulatory bodies, continually reviewing updates as pertains to regulatory changes and implement those changes within current departmental practices, policies and procedures.
Makes suggestions for policies and procedures covering all regulatory and accreditation standards for all lines of business.
Work Environment
Work is typically performed in an office environment. Ability to travel is required. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements in this profile are not intended to be all-inclusive. They represent typical elements considered necessary to successfully perform the job.
Education & Experience
Education: High School Diploma or Equivalent (GED) - (Required)
Experience: Minimum of 5 years Relevant experience - (Required)
Relevant experience may be a combination of related work experience and degree obtained (Associate’s Degree = 2 years; Bachelor’s Degree = 4 years).
Benefits
We offer healthcare benefits for full time and part time positions from day one, including vision, dental and domestic partners.
Equal Opportunity Statement
We are proud to be an affirmative action, equal opportunity employer. All qualified applicants will receive consideration for employment regardless of race, color, religion, sex, sexual orientation, gender identity, national origin, disability or status as a protected veteran. Women and Minorities are encouraged to apply. All qualified applicants will receive consideration for employment and will not be discriminated against on the basis of disability or their protected veteran status.
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