Grievance and Appeals Coordinator

Job ID: J138673
Company: Highmark Inc
Location: Pittsburgh, PA, United States
Full/Part Time: Full time
Job Type: Regular
Posted at: Jan 11, 2019

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Description

JOB SUMMARY

The job receives, researches and correctly classifies all grievance and appeals cases.  This includes any escalated step of the grievance and appeals process in accordance with state and federal regulatory requirements and state and federal regulations set forth for government products.  

ESSENTIAL RESPONSIBILITIES

  • Perform intake, correct and timely classification and routing of all appeal & grievance work types received at the health plan via all methods.   Perform routine research and evaluate basic output requirements.  Communicate business operational requirements to internal groups responsible for compliant handling.  Requires a strong understanding of regulatory definitions and requirements. 
  • Support the coordination, monitoring, and information gathering and reporting on the progress of cases to ensure adherence to defined project schedule.  Communicate effectively with colleagues. Successfully articulate issues, problems, and solutions. Participate in pre-and post-implementation review.  Assist in the planning, designing, and facilitation of functional walk-throughs.  May require additional support from more experienced team members.
  • Provide functional support to the appeal processing and clinical review teams.  Assist with small to intermediate cross-functional projects and change initiatives involved in the design and delivery of business process solutions, implementation strategies, and control measures and influencing organizational change related to business processes and models.
  • Accurate documentation of cases in the appeals management system, maintaining compliance with CMS reporting and data validation requirements.  Participate in process improvement meetings and/or discussions, recommending process efficiences.  Assist in development of desktop procedures and/or training materials. 
  • Other duties as assigned.

EDUCATION

Required

  • High School Diploma/GED

Substitutions

  • None

Preferred

  • None

EXPERIENCE

Required

  • 3 - 5 years in Customer Service

Preferred

  • 1 - 3 years in Appeals

LICENSES AND CERTIFICATIONS

Required

  • None

Preferred

  • None

SKILLS

  • Customer Service
  • Communication Skills
  • CMS Regulations
  • Claims Processing

Language (Other than English)

None 

Travel Required

0%  - 25%

PHYSICAL, MENTAL DEMANDS and WORKING CONDITIONS

Position Type

Office-Based

Teaches / trains others regularly

Occasionally

Travel regularly from the office to various work sites or from site-to-site

Rarely

Works primarily out-of-the office selling products/services (sales employees)

Never

Physical work site required 

Yes

Lifting: up to 10 pounds

Constantly

Lifting: 10 to 25 pounds

Occasionally

Lifting: 25 to 50 pounds

Rarely

Disclaimer: The job description has been designed to indicate the general nature and essential duties and responsibilities of work performed by employees within this job title. It may not contain a comprehensive inventory of all duties, responsibilities, and qualifications required of employees to do this job.

Compliance Requirement: This job adheres to the ethical and legal standards and behavioral expectations as set forth in the code of business conduct and company policies.

Summary

The job receives, researches and correctly classifies all grievance and appeals cases.  This includes any escalated step of the grievance and appeals process in accordance with state and federal regulatory requirements and state and federal regulations set forth for government products.  

Highmark Health and its affiliates prohibit discrimination against qualified individuals based on their status as protected veterans or individuals with disabilities, and prohibit discrimination against all individuals based on their race, color, religion, sex, national origin, sexual orientation/gender identity or any other category protected by applicable federal, state or local law. Highmark Health and its affiliates take affirmative action to employ and advance in employment individuals without regard to race, color, religion, sex, national origin, sexual orientation/gender identity, protected veteran status or disability.
EEO is The Law
Equal Opportunity Employer Minorities/Women/ProtectedVeterans/Disabled/Sexual Orientation/Gender Identity (http://www1.eeoc.gov/employers/upload/eeoc_self_print_poster.pdf)
We endeavor to make this site accessible to any and all users. If you would like to contact us regarding the accessibility of our website or need assistance completing the application process, please contact number below.
For accommodation requests, please call HR Services at 844-242-HR4U or visit HR Services Online at HRServices@highmarkhealth.org

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