[Hiring] Appeals & Grievances Coordinator @Point32Health

Role Description

The Appeals and Grievance (A&G) Coordinator is responsible, per State and Federal regulations, for assisting with all operational aspects of the Appeals and Grievances assignment process for Point32Health. Responsibilities include:

• Processing daily mail received by the AG department
• Handling outgoing mail for the AG department
• Distribution and classification of cases in compliance with applicable timeframes and regulations
• Gathering information on behalf of the AG Analyst with external vendors
• Coordinating the request for medical records
• Tracking effectuations
• Facilitating delivery of appeals and related information to key departments and appeals committee members
• Analyzing and reporting data regarding department processes as requested from management
• Noting trends in Appeals and Grievances and notifying supervisors of their findings

The coordinator must possess a broad understanding of all Point32Health lines of business and benefit structures as well as have an understanding of regulatory requirements and timeframes. Essential functions will occur simultaneously; therefore, the employee must be able to appropriately handle each of these functions, prioritize them, and seek assistance when necessary.

Qualifications

• Required (minimum): Associate’s Degree or equivalent experience in health care, conflict resolution or related field
• Preferred: 1-2 years of member services representative/customer service experience in health care
• Preferred: 1-2 years’ Appeals and Grievance experience in assigning and handling appeals and grievances

Requirements

• Excellent organizational skills required
• Excellent interpersonal/communication skills are essential
• Must have computer skills with experience in EXCEL and WORD
• Must have knowledge and demonstrated ability in the use of Windows applications and other comparable systems/applications
• Knowledge of basic medical terminology
• Ability to identify urgent situations and follow the appropriate protocol
• Ability to manage multiple priorities
• Initiative, judgment, and perception to operate within a fast-paced, high-stress environment
• Strong organizational, logical reasoning, analytical, and problem-solving skills
• Attention to detail necessary to act within this complex environment
• Ability to work independently and identify when to ask for help
• Flexibility to respond to changing needs in the Department
• Ability to work closely with other department staff
• Work coverage plan in place for scheduled and unscheduled absences
• Excellent interpersonal skills and ability to recognize and understand sensitive customer-oriented issues
• Daily contact, by telephone, with members, providers, and internal departments

Benefits

• Medical, dental and vision coverage
• Retirement plans
• Paid time off
• Employer-paid life and disability insurance with additional buy-up coverage options
• Tuition program
• Well-being benefits
• Full suite of benefits to support career development, individual & family health, and financial health