Sr Grievance and Appeals Coordinator
Albuquerque NM 87113
Job DescriptionPerforms research and analysis of appeals filed by members, customers, and government entities to administer timely resolution within state and federal guidelines, benefit plan guidelines, and company policies and procedures. Maintains a caseload of appeals and performs assigned duties.
- Analyzes and renders final decisions of non-clinical appeals according to procedure, state and federal guidelines, benefit plan guidelines, company internal policies and work flows.
- Coordinates the clinical appeal process through the collection of clinical records and consultation with Physician Advisors/Medical Director and communicates final determination.
- Consults with internal departments such as Clinical, Legal, and Network, as well as company senior management to assure appeal and complaint decisions meet all guidelines and result in customer satisfaction when possible.
- Consults with Account Management and external vendors to resolve high profile, complex appeals and/or complaints.
- Responsible for preparation of written detailed case history and presentation of second level appeal cases to the Appeals Panel for final company determination.
- Documents process and findings within the Appeals and the Complaint databases, and the company's internal systems.
- Responsible for interface with members and providers as required regarding status, process and outcomes of complaints and appeals.
- Responsible for maintaining the integrity of the company's relationship with client customers by researching, resolving and responding to customer and account inquiries involving adverse determinations.
- Responsible for identifying risk situations, consulting with senior management staff and rendering determinations that could adversely affect the company.
- Researches, compiles and consults with external review organization and customers as necessary for appeals and complaint process.
- Assists in data gathering and reporting of appeals. Responsible for achieving and maintaining department performance guarantees.
- Contributes to unit and department CQI (continuous quality improvement) processes by participating in unit goal setting, scorecard development and departmental meetings. Meets individual performance standards.
BA/BS Preferred, Behavioral Health Experience required
Prefer claims background experience and customer service.
BA/BS Preferred, with customer service and claims experience in behavioral health.
General Job Information
TitleSr Grievance and Appeals Coordinator
Job FamilyQuality Group
CountryUnited States of America
FLSA StatusUnited States of America (Non-Exempt)
Recruiting Start Date8/28/2019
Date Requisition Created8/28/2019
EducationGED (Required), High School (Required)
License and Certifications - Required
License and Certifications - Preferred
Other Job Requirements
- 2+ years experience in processing appeals and/or claims.
- Experience working in a contact center environment.
- 2+ years Behavioral Health, Healthcare or Managed Care Industry experience.
- Ability to talk on the telephone and type on a computer simultaneously.
- Working knowledge Microsoft Product Suite.
- Ability and willingness to learn new software applications.
Magellan Health Services is proud to be an Equal Opportunity Employer and a Tobacco-free workplace. EOE/M/F/Vet/Disabled. Every employee must understand, comply and attest to the security responsibilities and security controls unique to their position.
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