This position is accountable for the comprehensive review, research and resolution of appeals and grievances submitted by both members and providers. This position is required to apply analytical and critical thinking when reviewing contract language, benefits, and covered services in researching and providing an accurate and appropriate resolution in accordance with the Centers for Medicare and Medicaid Services (CMS) and the state of Nevada Division of Insurance. The appeal and/or grievance can include, but is not limited to customer service, claims, referrals, eligibility, and benefit issues. This position is also responsible for compilation of such data as needed to identify areas for improvement, as well as keeping abreast of departmental issues and the need for revised/additional policies and procedures that will assist in the resolution of the appeal and/or grievance.

This position will be responsible to keep overall service issues in mind while resolving individual cases.

• Review and evaluate Medicare, Commercial and Self-Funded appeal requests in order to identify and triage member and provider appeals. Using internal systems, determines eligibility, benefits, and prior activity related to the claims payment or service denial issues related to Medicare appeal requests. Completes cases within CMS and DOI regulations.

• Requests and reviews medical records, notes, and/or detailed bills as appropriate; formulates conclusions per protocol and other business partners to determine response; assures timeliness and appropriateness of responses per state, federal and Hometown Health guidelines.

• Prepares case files (original denial, all information received on appeal, medical records, and case summary for external reviewers, DOI, 2nd level review committee, OCHA, and/or arbitrators.

• Prepares, develops, and presents written case summaries, if needed and process dictates, for all adverse determinations for the purpose of litigation and arbitration.

• Maintains accurate, timely, and complete record of appeals and grievances in the appeals system and documents, all correspondence with a member/provider related to an appeal or grievance issue.

• Facilitates comprehensive processing of Medicare appeals to independent review organization (IRO) timely to meet regulatory turnaround times and protect our CMS Star Ratings.

• Responsible for accurate identification of all Commercial and Self-Funded grievance and appeals.

• Achieve a high level of workload volume, ensuring accuracy and compliance to scheduled regulatory deadlines. Monitors caseload daily to ensure all cases are kept in compliance, follows up and escalates when compliance standards are at risk.

• Escalates to manager when in need of the involvement of the legal department or compliance department for clarification and supporting documentation.

• Initiate and follow up on the effectuations (UM authorization/claim adjustment) for overturned appeals/grievances.

• Refer matters that involve problems that can develop negatively towards Hometown Health or matters affecting the department’s operating and capital budgets directly to Leadership.

• Collaboration with all Hometown Health departments, members, employers, brokers and providers and high standards of courteousness, performance, diplomacy, and respect for confidentiality.

• Collaborate with clinical staff for clinical related questions or issues. Licensed health professionals are on site as well as available virtually.

• Review and evaluate all grievances, appeals and complaints submitted to the organization while adhering to established timelines and initiate electronic tracking and distribution to the appropriate department for resolution.

• Responsible for timely completion of all audit findings on appeals to ensure accurate appeal and grievance universes can be supplied upon request.

• Identify and keep management informed of themes and/or trends related to service and recommend solutions to these issues.

• Identify complex problems and provide a resolution as it pertains to appeals and grievances.

• Participate in the development of Standard Work to improve the quality and service to our customers.

KNOWLEDGE, SKILLS & ABILITIES

• Strong customer service skills with the ability to provide service recovery immediately as needed.

• Working knowledge of medical billing practices to include, but not limited to medical terminology, CPT ICD9/10, and HCPCS coding.

• The ability to communicate professionally and diplomatically, clearly, and concisely, both verbally and in writing.

• The ability to maintain confidentiality of medical and personal information of all customers.

• The ability to ensure all goals and deadlines are met.

• Demonstrated skills in problem identification, problem solving and process improvement.

• Masters’ CMS regulations for handling Medicare appeal and grievance cases.

• Ability to Interpret and explain the benefits, policies and procedures to members and providers as they relate to grievances, appeals and complaints. Communicate with members/providers as necessary to provide updates or obtain additional information needed for decision making.

• Strong written communication skills with the ability to generate initial member acknowledgment (verbal and/or written).

• Ability to track and monitor movement of assigned cases through functional units and systems while ensuring that resolution meets established timelines.

• Follow-up with responsible departments and delegated entities to ensure compliance.

• Document final resolutions along with all required data to facilitate accurate reporting.

• Ensures final resolution letters are generated within the required timelines.

• Quality checks member and provider facing letters and when appropriate obtains legal opinion on language.

• Build effective and successful interdepartmental relationships with all areas of the organization and utilizes good communication and customer service skills in responding to internal and external inquiries about the grievance, appeal and complaint process while being able to respond quickly regarding the status.

• Participates in the compiling of all grievance, appeal and complaint records selected for on-site audits.

• Assists in developing workflows and innovative process improvements to positively impact the department overall.

This position does not provide patient care or make clinical decisions.

The foregoing description is not intended to be, and should not be construed as, an exhaustive list of all responsibilities, skills, efforts, or working conditions associated with the job. It is intended to be an accurate reflection of the general nature and level of the job.

Name

Description

Education:

Must have working-level knowledge of the English language, including reading, writing and speaking English. Bachelors’ Degree in Business Administration or related field preferred, but will consider collective experience, training, and education.

Experience:

Three years’ experience processing health insurance appeals and grievances or equivalent experience in health insurance claims, customer service, billing, or related operations preferred. Strong knowledge of claims operations and health plan customer service policies, procedures, and systems. Medicare experience preferred. Knowledge of state and federal insurance regulations with emphases on the Centers for Medicare and Medicaid Services (CMS). Must have excellent verbal and written communication and organizational skills.

License(s):

None

Certification(s):

None

Computer / Typing:

Must be proficient with Microsoft Office Suite, including Outlook, PowerPoint, Excel, and Word and have the ability to use the computer to complete online learning requirements for job-specific competencies, access online forms and policies, complete online benefits enrollment, etc.