Grievance & Appeals Specialist III

Job Summary:

The Grievance & Appeals Specialist III, in collaboration with department leadership, is responsible for processing and responding to claim appeals and disputes, and provides the department with subject matter expertise in clinical and code edit denials.

Essential Functions:

• Review a variety of appeals including, but not limited to: high difficulty appeals, consent appeals, state complaints, dental appeals, low difficulty appeals, member and provider appeals, non-clinical appeals (i.e. tobacco surcharge, etc.), medically frail appeals, RCP appeals
• Prepare the appeals for clinical review and be responsible for recording and tracking on a regular basis
• Review submitted appeals daily for validation of the appeal
• Identify appropriate claim problem within the appeal
• Prepare all clinical edit appeals for review by computer research, print claim from Facets system, and print off all the code descriptions to assist the reviewer in decision making for committee meetings
• Maintain spreadsheet of all appeals reviewed with the outcomes resulting from the Appeals Committee Meetings
• Document within Facets the detailed information as to the outcome of the claim appeal
• Identify System changes, log the ticket and track the resolution
• Complete claim appeal through claim adjustments or letters of denials
• Interact with other departments such as Medical Management, Provider Operation, Provider Service Center and claims
• Review claim appeals for possible fraud and abuse and report to Program Integrity
• Research and release claim appeals with other health insurance, notifying the COB unit when there is other insurance
• Responsible for reviewing and evaluating as a secondary-level review and decision maker on medical record documentation for claims and/or appeals to ensure diagnostic and procedural codes accurately reflect and support the visit as it relates to correct coding guidelines and medical necessity
• Analyze and make a determination of appropriate reimbursement for unlisted and by report codes submitted on claims
• Responsible for meeting CareSource and associated department standards for timeliness of review claims while maintaining accuracy of medical decisions
• Read and interpret medical procedures and terminology by reviewing medical notes
• Resolve assigned appeals within regulatory timeframes, achieve departmental quality expectations, and meet daily production requirements
• Identify and log any related issues
• Prepare packets for and participate in Non Clinical State Fair Hearings
• Conduct external review and IRE process for non-clinical requests
• Provide escalated effectuation support
• Investigation of Recoupment and Arbitration appeals
• Provide support to Customer Care Specialists and G&A Specialists to ensure all member grievance and appeals are captured and resolved
• Assist Team Leader with monitoring the daily activities of grievance processing for all lines of business
• Ensure all grievances are completed timely
• Ensure member appeals, access and quality of care issues are resolved within the appropriate time constraints
• Assist with the completion required reporting
• Assist with the training of new Grievance Specialist and Customer Care Specialists
• Assist with the periodic review of grievance and appeals procedures and workflows
• Ensure all state inquiries receive responses
• Assist with tracking and trending of grievance and appeals data, analyze information to develop proactive interventions
• Maintain grievance and appeal information and supporting documentation in accordance with state requirements
• Ensure all HIPAA and State requirements/regulations are adhered to at all times
• Mentor new staff
• Research and resolve CTM  complaints
• Assist in resolving member and provider grievances, appeals, corporate escalations, state complaints, and BBB complaints
• Meet daily production requirements, resolve assigned grievances within regulatory timeframes, and achieve departmental quality expectations
• Perform root cause analysis and associated documentation 
• Serve as an in-person grievance point of contact
• Perform UAT testing when necessary
• Perform any other job related instructions, as requested

Education and Experience:

• High school diploma or equivalent required
• Associates Degree or equivalent years of relevant work experience preferred
• A minimum of three (3) years of healthcare customer service, claims, compliance or related experience is required, to include one (1) year of coding experience

Competencies, Knowledge and Skills:

• Intermediate level skills in Microsoft Word & Excel with Access skills a plus
• Strong written and communication skills (written, oral and interpersonal)
• Attention to detail
• Ability to work independently and within a team environment
• Critical listening and thinking skills
• Technical writing skills
• Time management skills
• Proper phone etiquette
• Customer service oriented
• Decision making/problem solving skills
• Strong language skills
• Ability to write comprehensive statements using proper grammar and sentence structure
• Ability to multitask

Licensure and Certification:

• Certified Medical Coder (CPC, RHIT or RHIA) is preferred

Working Conditions:

• General office environment; may be required to sit or stand for extended periods of time

Compensation Range:

CareSource takes into consideration a combination of a candidate’s education, training, and experience as well as the position’s scope and complexity, the discretion and latitude required for the role, and other external and internal data when establishing a salary level. In addition to base compensation, you may qualify for a bonus tied to company and individual performance. We are highly invested in every employee’s total well-being and offer a substantial and comprehensive total rewards package.

Compensation Type (hourly/salary):

Organization Level Competencies

• Fostering a Collaborative Workplace Culture

• Cultivate Partnerships

• Develop Self and Others

• Drive Execution

• Influence Others

• Pursue Personal Excellence

• Understand the Business

This job description is not all inclusive. CareSource reserves the right to amend this job description at any time. CareSource is an Equal Opportunity Employer. We are dedicated to fostering an environment of belonging that welcomes and supports individuals of all backgrounds.