Job Summary:

Grievance & Appeals Coordinator I, in collaboration with department leadership, is responsible for all daily appeals logging and coordination of all State Hearings.

Essential Functions:

• Ensure regulatory compliance and HIPAA guidelines are met for Medicaid, Medicare, and future lines of business
• Document appeals in Facets
• Request medical/dental records from providers
• Prepare all appeals and grievances and forward to the appropriate team once the information is received
• Log State Hearings for Clinical Appeals Nurses
• Complete appeal and State Hearing files to be ready for filing
• Provide support to the department, including filing, printing, copying, including the preparation of new appeal and State Hearing files
• Examine and identify ways to improve existing processes/workflows
• Perform any other job-related functions as requested
• Perform triage on incoming mail, emails, and faxes
• Scan mail for retention in electronic files
• Log and index grievances and appeals in Facets and Onbase
• Create and mail acknowledgment letters for grievances and appeals
• Forward State Hearing requests, external review requests and ALJ requests to the appropriate Market
• Perform UAT Testing when necessary
• Research appeals/grievances to determine validity
• Log all appeals/grievances upon receipt in Facets
• Stamp and sort incoming mail and direct or assign as appropriate
• Route appeals to appropriate clinical personnel after documenting in Facets
• Identify, sort, and deliver logged appeals/grievances for processing
• Print and mail letters on denied appeals
• Report monthly key statistics for all lines of business to the management team
• Adhere to all policies and procedures, and ensure all guidelines set by regulatory bodies are followed and met
• Perform any other job duties as requested

Education and Experience:

• High School Diploma or equivalent required
• Associate Degree preferred
• Minimum of one (1) year of customer service, healthcare administration/management, or grievance and appeals experience required
• Managed Care experience preferred

Competencies, Knowledge and Skills:

• Ability to analyze information
• Communication skills
• Ability to work independently and within a team environment
• Excellent communication skills (both written and verbal) and ability to work with multi-disciplinary departments across the organization
• Effective organizational and prioritization skills
• Ability to manage time effectively
• Attention to detail
• Proper grammar usage
• Critical listening and thinking skills
• Proper phone etiquette
• Customer service oriented
• Decision making/problem solving
• Change resiliency
• Ability to accurately communicate summary information in a written format
• Intermediate computer skills; Microsoft Word, Excel, and Access

Licensure and Certification:

• None

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.