Position Purpose
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This position is accountable for continued success of all A&G Coordinators and the A&G Department. This position will provide support for the department to ensure that all appeals and grievances are managed correctly and timely with accurate information accordance with the applicable plan documents, policies and procedures, state and federal regulations. This position is required to have extensive knowledge and experience with health insurance products, including but not limited to Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), Third Party Administrator (TPA), Medicare Advantage and Prescription Drug (MA-PD), Dental, Vision and Pharmacy plans. This position is responsible to appropriately handle escalated appeals, complaints, concerns and education with high standards of courteousness, performance, diplomacy and respect for confidentiality is essential. This position must be able to identify and resolve any operational or service-related issues, set goals and priorities, and represent the department in a professional manner. This position shall participate in the quality improvement and change management process. Acts as a liaison between all customers, coordinators, and other Hometown Health/Renown Health departments. This position provides thorough, complete and accurate training of computer systems and insurance benefits to new and existing employees.
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Nature and Scope
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This position provides appropriate responses to all internal and external customers regarding Plan benefits to include, but not limited to eligibility, provider network, referral and authorization process, claims payment, policies and procedures. This position is also required to keep A&G Department Leadership and other appropriate Hometown Health Leadership informed of customer opinions, employee opinions, viewpoints and training needs. The information will be used in policy formation, benefit plan design, marketing efforts, and member retention and employee engagement. In addition this position requires the following: * Ability to extensively and thoroughly research inquiries and issues including vendor relationships, system issues, non-responsiveness, plan document interpretation, and outside department general operations. * Responsible to train and ensure that all coordinators are providing quality service and accurate information. * Strong customer service skills with the ability to provide service recovery immediately as needed. * Working knowledge of medical billing practices to include, but not limited to medical terminology, CPT ICD9/10, and HCPCS coding. * Assists the coordinators in the research of complex customer issues. * Responsible to keep the coordinators updated on the current benefit structures of the plans offered by Hometown Health through documents and team meetings. * Update the training manual on an as-needed basis. * Manage CMS CTMs and provide updates in CMS portal on resolution meeting required TATs. * Demonstrated skills in problem identification, problem solving and process improvement. * Reviews and evaluates Medicare appeal requests and electronic inquiries in order to identify and classify member and provider appeals. Using internal systems, determines eligibility, benefits, and prior activity related to the claims payment or service denial issues related to Medicare appeal requests. Completes cases within CMS regulations. * Facilitates processing of Medicare appeals to independent review organization (IRO). * Masters CMS regulations for handling Medicare appeal and grievance cases. * Responsible for accurate identification of all commercial and Self-Funded grievance and appeals. * Review and evaluate all grievances, appeals and complaints submitted to the organization while adhering to established timelines and initiate electronic tracking and distribution to the appropriate department for resolution. * Interprets and explains the benefits, policies and procedures to members and providers as they relate to grievances, appeals and complaints. * Communicate with members/providers as necessary to provide updates or obtain additional information needed for decision making. * Tracks and monitors movement of assigned cases through functional units and systems while ensuring that resolution meets established timelines. * Document final resolutions along with all required data to facilitate accurate reporting. * Ensures final resolution letters are generated within the required timelines. * Quality checks member and provider facing letters and when appropriate obtains legal opinion on language. * Builds effective and successful interdepartmental relationships with all areas of the organization and utilizes good communication and customer service skills in responding to internal and external grievances This position does not provide patient care.
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Disclaimer
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The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.
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Minimum Qualifications
Requirements - Required and/or Preferred
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Name
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Description
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Education:
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Must have working-level knowledge of the English language, including reading, writing and speaking English.
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Experience:
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Bachelors' Degree in Business Administration or related field preferred, but will consider collective experience, training and education. Minimum of 2 years demonstrated successful experience working in an appeals and grievance coordinator position. Working knowledge of state and federal insurance regulations with emphases on the Centers for Medicare and Medicaid Services (CMS).
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License(s):
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None
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Certification(s):
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None
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Computer / Typing:
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Must be proficient with Microsoft Office Suite, including Outlook, PowerPoint, Excel and Word, and use department specific computer applications, online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.
|
|
Position Purpose
|
This position is accountable for continued success of all A&G Coordinators and the A&G Department. This position will provide support for the department to ensure that all appeals and grievances are managed correctly and timely with accurate information accordance with the applicable plan documents, policies and procedures, state and federal regulations. This position is required to have extensive knowledge and experience with health insurance products, including but not limited to Health Maintenance Organization (HMO), Preferred Provider Organization (PPO), Third Party Administrator (TPA), Medicare Advantage and Prescription Drug (MA-PD), Dental, Vision and Pharmacy plans. This position is responsible to appropriately handle escalated appeals, complaints, concerns and education with high standards of courteousness, performance, diplomacy and respect for confidentiality is essential. This position must be able to identify and resolve any operational or service-related issues, set goals and priorities, and represent the department in a professional manner. This position shall participate in the quality improvement and change management process. Acts as a liaison between all customers, coordinators, and other Hometown Health/Renown Health departments. This position provides thorough, complete and accurate training of computer systems and insurance benefits to new and existing employees.
|
|
|
Nature and Scope
|
This position provides appropriate responses to all internal and external customers regarding Plan benefits to include, but not limited to eligibility, provider network, referral and authorization process, claims payment, policies and procedures. This position is also required to keep A&G Department Leadership and other appropriate Hometown Health Leadership informed of customer opinions, employee opinions, viewpoints and training needs. The information will be used in policy formation, benefit plan design, marketing efforts, and member retention and employee engagement. In addition this position requires the following: * Ability to extensively and thoroughly research inquiries and issues including vendor relationships, system issues, non-responsiveness, plan document interpretation, and outside department general operations. * Responsible to train and ensure that all coordinators are providing quality service and accurate information. * Strong customer service skills with the ability to provide service recovery immediately as needed. * Working knowledge of medical billing practices to include, but not limited to medical terminology, CPT ICD9/10, and HCPCS coding. * Assists the coordinators in the research of complex customer issues. * Responsible to keep the coordinators updated on the current benefit structures of the plans offered by Hometown Health through documents and team meetings. * Update the training manual on an as-needed basis. * Manage CMS CTMs and provide updates in CMS portal on resolution meeting required TATs. * Demonstrated skills in problem identification, problem solving and process improvement. * Reviews and evaluates Medicare appeal requests and electronic inquiries in order to identify and classify member and provider appeals. Using internal systems, determines eligibility, benefits, and prior activity related to the claims payment or service denial issues related to Medicare appeal requests. Completes cases within CMS regulations. * Facilitates processing of Medicare appeals to independent review organization (IRO). * Masters CMS regulations for handling Medicare appeal and grievance cases. * Responsible for accurate identification of all commercial and Self-Funded grievance and appeals. * Review and evaluate all grievances, appeals and complaints submitted to the organization while adhering to established timelines and initiate electronic tracking and distribution to the appropriate department for resolution. * Interprets and explains the benefits, policies and procedures to members and providers as they relate to grievances, appeals and complaints. * Communicate with members/providers as necessary to provide updates or obtain additional information needed for decision making. * Tracks and monitors movement of assigned cases through functional units and systems while ensuring that resolution meets established timelines. * Document final resolutions along with all required data to facilitate accurate reporting. * Ensures final resolution letters are generated within the required timelines. * Quality checks member and provider facing letters and when appropriate obtains legal opinion on language. * Builds effective and successful interdepartmental relationships with all areas of the organization and utilizes good communication and customer service skills in responding to internal and external grievances This position does not provide patient care.
|
|
|
Disclaimer
|
The foregoing description is not intended and should not be construed to be an exhaustive list of all responsibilities, skills and efforts or work conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.
|
|
|
Minimum Qualifications
Requirements - Required and/or Preferred
|
Name
|
Description
|
Education:
|
Must have working-level knowledge of the English language, including reading, writing and speaking English.
|
Experience:
|
Bachelors' Degree in Business Administration or related field preferred, but will consider collective experience, training and education. Minimum of 2 years demonstrated successful experience working in an appeals and grievance coordinator position. Working knowledge of state and federal insurance regulations with emphases on the Centers for Medicare and Medicaid Services (CMS).
|
License(s):
|
None
|
Certification(s):
|
None
|
Computer / Typing:
|
Must be proficient with Microsoft Office Suite, including Outlook, PowerPoint, Excel and Word, and use department specific computer applications, online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.
|
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Renown Health
Feb 19, 2025