AmeriHealth Caritas Coordinator Grievance and Appeals in Philadelphia, Pennsylvania
Coordinator Grievance and Appeals
Location: Philadelphia, PA
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At AmeriHealth Caritas, we’re passionate about helping people get care, stay well and build healthy communities. As one of the nation's leaders in health care solutions, we offer our associates the opportunity to impact the lives of millions of people through our national footprint of products, services and award-winning programs. AmeriHealth Caritas is seeking talented, passionate individuals to join our team. Together we can build healthier communities. If you want to make a difference, we’d like to hear from you.
Headquartered in Philadelphia, AmeriHealth Caritas is a mission-driven organization with more than 30 years of experience. We deliver comprehensive, outcomes-driven care to those who need it most. We offer integrated managed care products, pharmaceutical benefit management and specialty pharmacy services, behavioral health services, and other administrative services. Discover more about us at www.amerihealthcaritas.com .
The Grievance Coordinator is responsible for ensuring that all problems, complaints and grievances, presented by members or their representative are resolved in accordance with established policy and procedures, Department of Human Services, NCQA, and Federal/State guidelines. The Grievance Coordinator acts as a member advocate and independently communicates with Advocacy Groups, Community Representatives, Providers, Physicians, Department of Human Services, Independence, AmeriHealth HMO, Inc., and all the Plan’s departments including but not limited to Legal and Government Affairs, to interpret and enhance understanding of policies and procedures for complaints and grievances. Responsible to act as a facilitator within the team and demonstrate superior skill in dealing with members and providers. The Grievance Coordinator acts independently when representing the company at meetings.
Assist member or provider, on behalf of the member, in filing a formal appeal. Reviews the information presented and clearly and accurately determines if a complaint or grievance is to be filed.
The Member Advocate which is a function of the grievance coordinator ensures that the member’s rights and access to care is maintained. They independently communicate with Internal and External departments including physicians, legal, government affairs.
Calls member, provider, physicians, attorney, etc. to explain the appeal process, the policy/ procedure related to the appeal and informs the member, provider etc. of their options including but not limited to not filing an appeal or Fair Hearing.
Gathers all necessary information for example, Letter of Medical Necessity, policies and documentation that describes the substance of the complaint or grievance and creates a file that will be distributed to the appeals panel.
Reviews information gathered to ensure that the Plan has followed their policy/ procedure and the regulatory requirements related to the appeal.
If the grievance coordinator determines that the Plan has not complied with all regulations related to the appeal, they notify the departments and an explanation is sent to that department informing the department of the appropriate action. The correction can include but are not limited to, rewriting the original outcome letter, keeping services in place or approving the service or medical equipment. This will be discussed with the Appeal Supervisor and / or manager.
Actively seeks the involvement of the legal department or government affairs, whenever necessary, for clarification and supporting documentation.
Documents, in the appropriate computer system, all correspondence with a member and or a provider surrounding an appeal or issue. Thoroughly researches questions and issues in order to provide an accurate explanation.
Uses sound judgment and discretion when communicating findings and PHI related to the appeal. When necessary, will obtain authorization for release of sensitive and confidential information. Keeping in mind the minimal necessary rule.
The grievance coordinator coordinates 1st and 2nd level appeal committee meetings. The grievance coordinator must accurately present the Plan’s policies/ procedures and the regulations under which the company functions. This information must be accurate and concise. The member, who has filed the appeal and the member’s representative, can attend the committee meeting. At the appeal meeting the member and their representative can ask the grievance coordinator questions about the Plan’s policies and procedures. The grievance coordinators statements are taken and become a permanent part of the appeal file. These files go to the Department of Health, Department of Insurance, Fair Hearing and DHS.
Tracks and reports case turn around time. Keeps abreast of all cases to ensure that the 30-day time limit for case resolution is meet on the 1st level and within 45 days for 2nd levels. Follows up, with supervisor when this requirement is not met. .
Keeps current with rules, regulations, policies and procedures relating to the Plan, member benefits, member’s rights and responsibilities, and Complaints and Grievances.
Obtains a member’s written consent when needed. Accurately completes the documents needed to obtain the member’s consent and forwards documents to the member and the member representative including Legal Counsel.
Demonstrates a professional and courteous manner when communicating with others.
Demonstrates flexibility with ability to set priorities within established deadlines and time frames. Works with supervisor on return calls to DHS and DOH within prescribed time frames.
Demonstrates independence and initiative in completing assignments and follow-up on matters.
Demonstrates active listening, oral and written skills as related to documenting the substance of the grievance. Accurately documents the outcome that the member or the provider on behalf of the member is seeking.
Demonstrates problem solving skills with the ability to analyze the information and draw conclusions.
Demonstrates attention to detail in the construction; completion of appeal files and dissemination of information.
Demonstrates ability to use the departmental database correctly adding information to assure accurate departmental reporting..
Demonstrates public speaking skills with emphasis on tone of voice, eye contact and the ability to deliver an accurate message and answer the question asked.
Maintains the performance standard of processing 100% of all member first level appeals within 30 days and second level appeals within 45 days of receipt, as defined in all regulatory and accreditation standards.
High School diploma or the equivalent required.AD or BA/BS in a health related field preferred.
5-7 years customer service with in a health care environment required.
Experience in an appeals environment required.
Medicaid and HMO experience required.
Knowledge of Microsoft Office Applications, Internet functions, data base applications.
Knowledge of the basic health care industry, managed care principles, and medical terminology preferred.
Proficiency with Microsoft Office applications (Excel, Word,)
Proficiency in use of related applications/internal systems to collect information necessary to.
Complete principal accountabilities (e.g., Healthcare System, MACESS/IMAX, Facets Internet).
Effective and accurate verbal and written communication skills.
Ability to plan own schedule set priorities and works independently in accomplishing work assignments on time.
EOE Minorities/Females/Protected Veterans/Disabled
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