Coord Appeals & Grievances

• Research and Investigate member and/or provider appeals and grievance requests, including review of UM/claim denial reasons, contract/regulatory rules, benefits, and documentation received on appeal/grievance
• Distribute meeting materials, reports, and follow-up documentation as needed.
• Facilitate, Manage, and guide panel meetings (i.e., telephonic, video conference and in-person) by enforcing guidelines, fostering order and engagement, and ensuring smooth and cohesive discussion.
• Communicate effectively with panel members, stakeholders, and leadership to ensure alignment and clarity of appeal(s).
• Maintain confidentiality, organization, and integrity in handling sensitive information.
• Upload recording, documentation, and transcription to capture key discussions and decisions.
• Outreach call(s) made to members/participants, providers and /or member/participant representatives, to acknowledge receipt of appeal/grievance and discuss intent of appeal/grievance
• Explain the appeal/grievance process including helping members understand the outcome and implication of appeals decisions
• Prepares case file (original denial, all information received on appeal, medical records, etc.)
• Schedule participant/member for committee panel sends scheduling letter if needed
• Prepares, develops and presents written case summaries, if needed and process dictates, for all adverse determination for the purpose of conducting State Fair Hearings
• Prepare and send cases files to other teams as needed (e.g. legal, external appeals, state fair hearings, etc.)
• Communicates updates and status of outstanding member and provider complaints/issues to management
• Monitors to ensure that all problems with appeals/grievances presented by plan members/participants are resolved in accordance with established policies and procedures
• Update and/or generate authorization updates requests, for services that have been appealed
• Maintains accurate, timely, and complete record of appeals and grievances in the appeals system and documents, all correspondence with a member/participant, representative and/or a provider, related to an appeal or grievance issue
• Maintains quality and compliance standards as dictated by the state and federal entities
• Maintains contractual agreements with participating providers related to appeals and grievances
• Monitors caseload daily to ensure all cases are kept within compliance; follows up and escalates when compliance standards are at risk
• Actively seeks the involvement of the legal department or compliance department, as necessary, for clarification and supporting documentation by escalating issues to appeals and grievances management
• Obtain authorization for release of sensitive and confidential information
• Keeps current with rules, regulations, policies and procedures relating to Plan member benefits, member’s rights and responsibilities, and Complaints and Grievances
• Ensure case file is sent to appropriate committee for decision making or example, internal committee/panel, independent review organization, internal medical director - as process dictates
• Provide support presenting cases and facilitating committee meetings as needed
• Send appeal to an independent review organization portal, for those appeals that require an external match specialty review
• Obtain data from multiple systems/vendors to ensure all documentation needed for appeal is obtained, for e.g. PerformRX, LTSS and other systems/vendors as needed
• Collaboration with internal counterparts as needed to ensure proper handling of the appeal e.g. UM team, medical directors, claims, contact center, vendors as needed (e.g. PerformRX)
• Creates decision letter with detail description of the nature of appeal / grievance including rational for the decision and options for moving forward
• Initiate and follow up on effectuations (um authorization update/claim adjustment) for overturned appeals/grievances

• Required High School/GED
• Required a minimum of two (2) years’ work experience in a Managed Care environment
• 1 to 3 years' experience in grievance/appeals environment required

• Proven experience as a facilitator or moderator /similar
• Experience organizing and managing meetings.
• Excellent verbal and written communication skills
• Ability to engage and manage diverse groups.
• Awareness and sensitivity to diverse cultural backgrounds
• Ability to create a positive environment.
• Ability to handle challenging situations and conflict constructively.
• Familiarity with presentation software, video conferencing tools ( Zoom & Team) and relevant technology
• Proficiency with Windows and Microsoft Office applications, including Excel, Access, PowerPoint and Outlook
• Knowledge of the basic health care industry, managed care principles, claims, and medical terminology
• Ability to work collaboratively or independently; deliver high-quality work; attention to detail and flexibility; excellent verbal and written communication skills communication skills

AmeriHealth Caritas