AmeriHealth Caritas Grievance Coordinator, Member Appeals in Philadelphia, Pennsylvania
Grievance Coordinator, Member 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 Keystone First Health Plan (KFHP) and AmeriHealth Caritas Health Plan (ACHP) members or their representative are resolved in accordance with established policy and procedures, Department of Public Welfare, 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 Public Welfare, Keystone Health Plan East, AmeriHealth HMO, Inc., and all KFHP/ACFC 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 IBC appeals committee meetings and other meeting happening outside the company.
Assists the 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.
Serves as a member advocate by ensuring the member’s rights and access to care is maintained. They independently communicate with Internal and External departments including physicians, legal, government affairs and the Department of Human Services.
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.
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 KF/ACP/ACN has followed their policy/ procedure and the regulatory requirements related to the appeal.
If the grievance coordinator determines that KF/ACP/ACN 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.
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 and does a summary of the meeting. The Appeal Committee is made-up of an IBC physician, manager, legal counsel and a member of the KF/ACP/ACN health plan. The grievance coordinator must accurately present KF/ACP/ACN policies/ procedures and the regulations under which the company functions. Their testimony 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 KFHP/ACHP policies and procedures. The grievance coordinators statements are taken verbatim and become a permanent part of the appeal file. These files go to the Department of Health, Department of Insurance, Fair Hearing and DPW.
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 KHPE/AmeriHealth, when this requirement is not met. Responsible for communicating DPW and NCQA requirements to appropriate personnel involved in the member appeal process.
Keeps current with rules, regulations, policies and procedures relating to KFHP/ACHP Plans member benefits, member’s rights and responsibilities, and Complaints and Grievances.
Obtain 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 with the ability to clearly and accurately state agreed upon resolutions.
Demonstrates flexibility with ability to set priorities within established deadlines and time frames. Return calls to DPW and DOH within prescribed time frames.
HS Diploma or equivalent required, Associate's Degree or Bachelor's in health related field preferred.
The selected candidate must be able to attend in person member appeals committee meetings. These meetings are in the Philadelphia region and can occur with limited notice.
Five to seven years of customer service experience within 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, and FACETS.
Effective and accurate verbal and written communication skills.
EOE Minorities/Females/Protected Veterans/Disabled